
Glass. 1PL 7/ 

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Copyright N° ! 



COPYRIGHT DEPOSE 




Morphcea. 

From Tenneson's Precis Iconographiques des Maladies de la Peau. 



THE 



READY REFERENCE HANDBOOK 



OF 



DISEASES OF THE SKIN 



BY 

GEORGE THOMAS JACKSON, M.D. 

PROFESSOR OF DERMATOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, NEW 

YORK CONSULTING DERMATOLOGIST TO THE PRESBYTERIAN HOSPITAL. 

NEW YORK, AND TO THE NEW YORK INFIRMARY FOR WOMEN 

AND CHILDREN ; MEMBER OF THE AMERICAN DERMATO- 

LOGICAL ASSOCIATION AND OF THE NEW YORK 

DERMATOLOGICAL SOCIETY, 



WITH 99 ILLUSTRATIONS AND 4 PLATES. 



SIXTH EDITION, THOROUGHL Y REVISED. 




LEA & FEBIGER, 

N i: \\ Y O R K A N J) PHIL A D B L P II 1 A. 
1908. 



IwoCtpies Hecwve* 

AUG 1 1908 

Owynf nt cnti* 
GW8S4 XXC. No, 

*;M\ 4 



Entered according to Act of Congress, in the year 1908, by 

LEA & FEBIGER. 

In the Office of the Librarian of Congress. All lights reserved 



PREFACE TO THE SIXTH EDITION. 



Iu the preparation of this revised edition every page 
has been carefully studied and much new matter incor- 
porated, as shown by the increase in size. The litera- 
ture of Dermatology has been critically examined. New 
articles have been added upon black tongue, dermatitis 
verrucosa or vegetans, keratosis follicularis contagiosa, 
keratosis senilis, lichen obtusus, melung, pseudo-pelade, 
and sporotrichosis hypodermica. The old sections on 
pathology have been revised and new ones added by 
Dr. S. I. Rainforth. He and Dr. S. Dana Hubbard have 
furnished some new photographs taken from cases occur- 
ring in the author's service at the Vanderbilt Clinic. 
Dr. John A. Fordyce has kindly allowed the use of one 
of his superb micro-photographs, that of molluscum con- 
tagiosum. The author takes pleasure in acknowledg- 
ing with thanks his obligation to these gentlemen for 
their assistance. He can ask nothing better for this 
edition than the same kindly reception that the profes- 
sion has given to the five editions that have preceded it. 

G. T. J. 

15 East Twenty-ninth Street, 
New York. 



DISEASES OF THE SKIN. 



PAET I. 



GENERAL CONSIDERATIONS. 

Anatomy and Physiology of the Skin. 

The skin varies in thickness in different regions from 
one-half to eight millimeters. It is composed of three 
distinct layers, namely : 1, the epidermis ; 2, the derma, 
also named the cutis vera, or corium ; and, 3, the sub- 
cutaneous connective tissue. The appendages of the 
skin are the hair, the nails, the sebaceous and the sweat 
glands. This complicated structure is supplied with 
bloodvessels, lymphatics, and nerves. 

Epidermis. The epidermis is composed of four 
layers, called strata, namely : 1, the stratum corneum ; 
2, the stratum lucidum ; 3, the stratum granulosum ; 
and 4, the stratum mucosum. Of these strata, the two 
that most concern us are the first and the last — that is, 
the stratum corneum and the stratum mucosum. The 
other layers of the skin may, for our present purpose, 
be regarded as simply transition-layers through which 
an epithelial cell passes on its developmental way to 
become a fully formed corneous cell. Each of the four 
strata of the epidermis is divided again into layers, but 
these are of no practical importance. The thickness of 
the epidermis varies from 0.25 to 1.65 mm., being 
thickest and most compact where it is subjected to the 
most pressure of intermittent character, as on the palms 
and soles. 

2 17 



18 



GENERAL CONSIDERATIONS, 
Fig. 1. 




Vertical section through the skin. Diagrammatic. (After Heitzmann.) 

The stratum corneum consists of a series of superim- 
posed layers of flattened, elongated cells that increase 
in flatness from below upward. The upper layers are 



ANATOMY AND PHYSIOLOGY 01 THE SKIN. 19 

called scales. The cells of each layer are united to each 
other so much closer than the layer itself is united to those 
above and below it that when an effusion takes place 
into the stratum corneum a layer of cells in the affected 
area is raised and the fluid is found between two layers. 
The lamellated scaling met with in certain scaly diseases, 
such as dermatitis exfoliativa, in which great plates of 
scales are readily removable, is likewise due to this close 
relation between the cells of each layer. This stratum is 
largely a protective one, its compactness affording a fair 
degree of resistance to injury of the underlying, more 
succulent layers of the epidermis. 

The stratum mucosum is the deepest layer of the epider- 
mis, and is seated upon the papillary layer of the corium. 
It is composed of several layers of cells, but may be 
considered as consisting of two chief layers, namely, 
the columnar epithelium and the prickle cells. The 
columnar epithelial cells are arranged perpendicularly 
to the papillae of the corium, while the prickle cells, 
which are polygonal in shape with spherical nuclei and 
with little filaments running out from their sides toward 
the neighboring cells, are arranged in strata over them. 
As the stratum granulosum, which lies above the stratum 
mucosum, is approached the prickle cells become flatter; 
and finally lie with their long axis parallel to the general 
surface. The " granules " contain eleidin (Ranvier) and 
keratohyalin (Waldeyer), the former being a fluid and 
the latter a solid substance. The stratum mucosum, also 
called the rete Malpighii, is the most important stratum 
of the epidermis, and the seat of that most common of all 
skin diseases, eczema. From its lower part it sends 
down projections between the papillae of the corium, 
which are called interpapillary projections. Most of the 
pigment of the skin is situated in the lower part of the 
stratum mucosum. As the upper part is approached less 
and less pigment is found. The pigment itself is in 
the form of granules and of diffused coloring-matter. 
According to Unna, the pigment is found even in the 



20 GENERAL CONSIDERATIONS. 

upper part of this layer, while iu pathological conditions 
it may be located in the corium. In the so-called colored 
races pigment is always found in the corium, and even 
the horny layer is stained. 

From this arrangement of the cells of the epidermis 
it will be seen that nutrient fluids can readily work 
upward from below by means of the little channels formed 
by the interlacing of the filaments running between 
the cells. 

The epidermis has no bloodvessels. It receives its 
nutrition entirely from the corium. Though there are no 
true lymphatics in the epidermis, there are abundant 
lymph spaces between the cells that take their place. 
Nerves of the non-medullated variety have been traced 
between the cells of the epidermis, and have been de- 
scribed by some histologists as entering into the cells to 
end at the nucleus, though not to enter it. The final 
distribution of the nerves in the epidermis is not yet 
fully determined. 

Corium. The corium is composed of white fibrous and 
yellow connective tissue, disposed in horizontal bundles 
above and in oblique bundles below. It is a very dense 
and tough tissue, and is pierced in all directions to allow 
of the passage of bloodvessels, lymphatics, sweat ducts, 
and nerves, and affords lodgement for the hair follicles 
and sebaceous glands. It contains a considerable amount 
of elastic fibers. The upper part has been named the 
pars papillaris, and the lower part the pars reticularis 
corii. From its upper part it sends off a vast number of 
projections called papilla?. These vary in length, being 
longest and most marked on the ends of the fingers and 
toes. The epidermis follows these projections and dips 
down between them. They are readily seen as parallel 
markings on the ends of the fingers. Over most of the 
body surface the papillae are but slightly raised, and 
merely give a wavy appearance to the upper edge of the 
corium when viewed under the microscope. As the lower 
part of the corium is reached the bundles of fibers are less 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 21 

closely crowded together, and becoming successively looser 
gradually pass over into the 

Subcutaneous connective tissue. This is a loose connec- 
tive tissue with large and small spaces in it, which are 
filled with adipose tissue. This consists of fat-cells col- 
lected into tabulated masses that in some cases have about 
them a connective-tissue sheath. Each lobule is sup- 
plied with an afferent artery, a capillary plexus about it, 
and efferent veins. This part of the skin is called the 
panniculus adiposus, and is found everywhere except in 
the skin of the penis, scrotum, labia minora, eyelids, 
pinna, and beneath the nails. It contributes to the 
roundness and beauty of the body, besides acting as a 
storehouse for fuel against such times as the body cannot 
gain its proper nutriment from food, as in fevers. It 
also gives lodgement to the coil or sweat glands, and aids 
in protecting the underlying parts from injury. The lower 
ends of the deep hair follicles are also in this part of the 
skin. The subcutaneous tissue merges into the underly- 
ing fasciae of the muscles and the periosteum of the bones. 
Under the name of columnce adiposes J. C. Warren has 
described certain prolongations of fatty tissue running up 
to the bases of the hair follicles. They are important in 
relation to the pathology of carbuncle. 

Bloodvessels. The arteries which supply the skin 
come up from below to form a horizontal plexus in the 
subcutaneous tissue, from which the vessels proceed per- 
pendicularly through the corium to form a second hori- 
zontal plexus just below the papillae. From the lower 
plexus small branches pass to the fat cells, sweat glands, 
and, according to Unna, the hair papillae. From the 
upper plexus branches are given off which enter the 
papillae of the skin. There are also branches to the hair 
follicles, sebaceous glands, and the tissue of the corium 
itself. Papillae that give lodgement to a tactile corpuscle 
have no arterial twig. The veins follow the same course 
as the arteries, but, of course, in the opposite direction. 

Lymphatics. Lymph vessels are large in the subcu- 



22 GENERAL CONSIDERATIONS. 

taneous tissue, smaller in the upper part of the eorium, 
and form plexuses. " Juice-spaces," filled with lymph, 
are found abundantly in the epidermis and papillae, about 
the glands of the skin, and around the muscles of the 
skin and the connective- tissue bundles and fat-lobules. 

Nerves. The skin is provided with both medullated 
and non-medullated nerve-fibers and motor and vasomotor 
nerves. We have learned already that non-medullated 
nerve-fibers have been traced between the cells of the 
epidermis, some terminating at, if not in, the nuclei of 
the prickle cells. It may be roughly stated that the 
nerves follow pretty much the same arrangement as the 
bloodvessels, forming a sort of plexus beneath the papillae 
and then giving off branches to the vessels, to the tactile 
corpuscles, to the papillae, the hair follicles, the sebaceous 
and the sweat glands, and the epidermis. 

The tactile corpuscles (corpuscles of Meissner) are 
located in the papillae. They are oval or rounded bodies, 
and their long axis runs longitudinally. Not more than 
one papilla in four is supplied with one of these corpus- 
cles, even where they are most abundant — on the end of 
the index finger. They are composed, according to Unna, 
of large, flat connective-tissue cells, which are placed one 
above the other like money-rolls, and take up between 
them the terminal branches of the medullated nerves, 
which on entering the bodies lose their medulla and finally 
end between the cells. The transversely striped appear- 
ance presented by the corpuscles is due to the swollen 
lateral edges of the cells and the band-like nerve-fibers 
that here and there appear upon the surface. 

The corpuscles of Krause are located in the sensory 
mucous membranes. They are rounded in shape and 
bear a close resemblance to the Pacinian corpuscles in 
structure. 

The Pacinian corpuscles are located in the subcutaneous 
tissues, and also in connection with the sensitive nerves. 
They are oval in form, visible to the naked eye, and con- 
sist in a colossal swelling-out of the sheath of Schwann, 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 23 

forming a thick connective-tissue capsule surrounding a 
much smaller cylindrical cavity filled with granular, 
faintly filamentous cellular substance, through the axis of 



Fig. 2. 




Hair in follicle. (After Kaposi.) 

a. Follicle mouth, b. Neck. c. Arch of follicle, d. Outer, e. inner 
sheath of follicle, p. Hair papilla, ra. Fat-cells, n. Erector pili muscle. 
ep. Epidermis, s. Mucous layer of epidermis, o. Skin papillae, t. 
Sebaceous glands. /. External, g. internal root sheath, h. Cortex of 
hair. k. Medullary canal. I. Hair root. 



which passes a sensitive nerve. As the latter enters the 
corpuscle it loses its medulla, and either terminates in 
the corpuscle or passes through it to enter one or more 
corpuscles. These corpuscles are most abundant in the 



24 GENERAL CONSIDERATIONS. 

fingers and toes, and the palms and soles. They are sup- 
posed to enable us to appreciate pressure or traction. 

Hair. The hair is an epidermic structure which grows 
from a nipple-shaped projection, the hair papilla, situated 
at the bottom of a deep, slender pocket or sac-like 
depression in the skin which is called the hair follicle. 
Commencing at the papilla it is bulb-shaped. This part 
is called the bulb and fits over the papilla like a cap. On 
leaving the papilla the body of the hair is first called the 
root y and then as it becomes narrower the shaft. The 
diameter of the shaft rapidly decreases until, leaving the 
skin, it terminates in the point. A fully formed hair is 
hollow, its central cavity being called the medullary canal 
and filled with the medulla. This is composed of a col- 
umn of cells arranged in layers, one layer being superim- 
posed on another. The main substance of the hair is 
called the cortex, and consists of long, spindle-shaped 
epithelial cells flattened out into fine bands which run in 
the long axis of the hair. This part of the hair gives 
it substance and strength, and in it is placed the pigment 
that determines the color of the hair. The outer layer 
of the hair is called the cuticle. It corresponds to the 
epidermis and consists of flattened, non-nucleated, fully 
cornified cells which cover the hair like scales and over- 
lap each other like shingles. 

The hair follicle is located, for the most part, in the 
corium, but in some very strong hairs it reaches down 
into the subcutaneous tissue. It is always, excepting at 
the dorsal edge of the eyelids, placed at an angle to the 
skin, and is a permanent structure that is not removed 
when the hair is plucked. It is composed of three layers, 
which are derived from the corium as it dips down to 
form the follicle. Between the follicle and the hair is the 
root sheath, which is derived from the epidermis. It is 
composed of two layers, which are called the external 
and the internal root sheaths. The whole arrangement 
of the hair and its sheath may be graphically conceived 
by regarding the hair as a blunt needle pressed against 



ANATOMY AND PHYSIOLOGY OF THE SKIN 25 

the skin. The needle would form the hair, the epidermis 
would form the root sheath, and the corium would be to 
the outside of all and form the hair follicle. 

Hair is found on all parts of the body excepting the 
palms and soles, the terminal phalanges of the fingers 
and toes, the glans penis, prepuce, labia minora, and the 
vermilion border of the lips. In form it is flattened or 
rounded, straight or curled. There are three main vari- 
eties of hair: 1. Long, soft hair, as of the head and 
beard. 2. Short, stiff hair, as of the eyebrows and eye- 
lashes; and, 3. Lanugo, or soft, downy, colorless hair 
that is scattered all over the surface of the body where 
the other varieties are not. 

Nails. The nails, like the hair, are epidermic struct- 
ures. They are placed on the extensor surfaces of the 
terminal phalanges of the fingers and toes. Their prox- 
imal end is called the root, under which is the matrix, 
from which they grow. On the way to their distal end 
they pass over the nail bed. This is separated from the 
matrix by a more or less convex and apparent line called 
the lunula. At their posterior and lateral margins they 
are imbedded in a fold of skin that is called the nail fold. 
At their distal extremity they are separated from the end 
of the finger or toe. They are formed by the matrix, but 
in passing over the bed they receive a certain amount of 
nourishment from it, and their cells become rapidly corni- 
fied. They are slightly curved from side to side, being 
convex above and concave below, and are marked with 
fine lines. The flesh beneath the nail is the same as the 
skin in general, though without subcutaneous tissue. The 
nail takes the place of the corneous and granular layers 
of the skin. It has been estimated that it takes from one 
hundred and eight to one hundred and sixty-one days for a 
finger nail to grow from the lunula to the free edge, the rate 
of growth being more rapid in summer than in winter. It 
has beeu noted that in a case of fracture of a limb the nails 
of the fingers or toes may cease growing until the bone is 
well knit. 



26 GENERAL CONSIDERATIONS. 

Sebaceous Glands. (Fig. 1.) These glands are of 
the racemose variety, and are closely related to the hairs, 
from two to six being attached to each hair, emptying by 
their ducts into the upper third of the follicle. Each 
gland is composed of a number of acini that empty by a 
common duct. They are composed of a delicate, struct- 
ureless capsule, the membrana 'propria, which continues 
along the duct to merge into the hair follicles. This is 
lined with large, although short, cubical or cylindrical 
epithelial cells arranged in one or two rows. These are 
continuous through the duct with the cylindrical cells of 
the outer root sheath of the hair and of the skin. The 
interior of the glands is filled with fatty secretion. 
Around the glands passes the external layer of the hair 
follicle. These glands occur also on the vermilion border 
of the lips, the labia minora, and the glans penis and pre- 
puce, though in these locations there are no hairs. 

The function of the sebaceous glands is to oil the hair 
and skin, thus rendering them soft and supple, and giving 
luster to the hair. This oily secretion, or sebum, is pro- 
duced by the cells, which, as they reach the central part 
of the acini, undergo fatty degeneration. It is composed 
of fats, fatty acids, cholesterin crystals, debris of cells, and 
water. It is forced out of the glands by the constant 
production of new sebum. The glands are largest in the 
nose, cheeks, scrotum, mons veneris, labia, and about the 
anus. There are no sebaceous glands in the palms and 
soles. 

Sweat Glands. (Fig. 1.) The sweat glands are simple 
coil glands that are located in the lower part of the corium 
and in the subcutaneous tissue. Their ducts ascend 
through the corium in a straight or wavy line to the inter- 
papillary spaces, where they enter the epidermis. The 
cells lining the coil are simple cubical epithelial cells. 
These are seated upon muscular fibers ; and a connective 
tissue, the membrana propria, comes outside of all. An 
abundant network of bloodvessels surrounds each gland 
and sends off branches to its interior. The glands are 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 27 

also richly supplied with nerves. The duct is made up 
of pavement-epithelium upon the membrana propria. 
AVhen the epidermis is reached the membrana propria is 
lost, and the further tract of the duct seems to be made 
by the sweat working its own channel up between the 
epidermic cells. The duct ends as a rounded aperture on 
the surface of the skin that is called a sweat pore. Unna 
teaches that the sweat produced by the coil glands is 
mixed with other elements while passing through the 
epidermis, so that the secretion that appears at the sweat 
pores is not the same as that which leaves the coils. He 
further teaches that the office of the coil glands is not to 
produce sweat, but to oil the skin. This theory still 
needs confirmation before it can be accepted as proven. 
His arguments have considerable weight, but space will 
not allow of their statement here. It has long been 
known that there was a certain amount of oil in the sweat. 
Sweat glands are most numerous in the palms and soles. 
Their diameter is from 0.3 to 0.4 mm. The largest are 
in the axillae, where they have a diameter of 2 to 7 mm. 
and are very numerous. In the external meatus of the 
ear they secrete the so-called ear wax. 

Muscles. The skin is provided with muscles, both of 
the striated and unstriated variety. The striated muscles 
are found in the face and neck. The majority of the 
muscles of the skin are involuntary muscles. In the 
scrotum they run parallel with the raphe. On the penis 
and about the nipple their direction is circular. The 
ar rector es pilorum muscles are found all over the body, 
running in a more or less oblique direction from the 
bottom of several papillae down and around a sebaceous 
gland to be attached to the bottom of a hair follicle. By 
contracting they raise the hairs to a perpendicular position 
and aid in pressing out the contents of the sebaceous 
glands. 



28 GENERAL CONSIDERATIOS. 



Physiology. 

The skin is a protective, sensory, heat-regulating, and 
secretory organ. It offers protection to the deep parts 
by the pad like structure of the subcutaneous tissue with 
its panniculus adiposus, and the highly resistant nature 
of the insensitive horny epidermis, both to physical and 
chemical agencies, and to the penetration of bacteria. 
The most vulnerable points in the skin are the pilo- 
sebaceous openings, and these are usually plugged with 
masses of sebum. 

The end organs of touch and temperature sensation 
are located in the skin, but the delicacy of these sensations 
varies markedly in different regions. Loss of sensation 
leads frequently to the formation of traumatic lesions in 
the anesthetic area. Little is known about the existence 
of trophic nerves, although the nutrition of peripheral 
parts seem to be influenced by the central nervous 
system. 

The skin plays a very important part in the regu- 
lation of the amount of heat lost by the body through 
evaporation, radiation and conduction. In man 77 to 
85 per cent, of the total heat loss of the body is through 
the skin. The regulation is effected through the blood 
supply and the sweat secretion. The efficiency with 
which the mechanism serves its purpose is evidenced by 
the fact that in a dry atmosphere a temperature of over 
250° F. will not produce any change in the body tem- 
perature as long as the sweat secretion remains active. 
When the body surface is exposed to cold, the sweat 
secretion is reduced to a minimum and the skin blanched 
by the contraction of the cutaneous vessels, under the 
control of the vasomotor centre. The emptying of the 
vessels is assisted by the contraction of the involuntary 
muscles of the skin, which increase the tension and the 
pressure around the vessels, and produce the condition 
known as goose-flesh (cutis anserina). 

The sweat is 99 per cent, water, and varies in amount 



DIAGNOSIS. 29 

from 600 to 1300 cc. a day, but may rise under stimu- 
lation as by heat or exercise, even to 400 cc. an hour. 
Besides its heat regulating function it serves also to 
remove small quantities of excretives from the body, and 
to keep pliable and moisten the epidermis. The sebum, 
besides lubricating the skin, prevents the absorption of 
aqueous solutions from without, and the evaporation of 
fluids from within. 

Diagnosis. 

The Lesions of the Skin. We speak of primary 
and secondary lesions of the skin. By the first of these 
terms we mean the form assumed by the efflorescence at 
its first appearance. By the second of these terms we 
mean the subsequent changes the primary lesion under- 
goes of itself, or as the result of extraneous causes acting 
upon it. In running its course, whether influenced by 
treatment or not, almost every disease of the skin exhibits 
more than one lesion, and we can only speak of it as a 
macular, papular, or other disease from its most promi- 
nent and characteristic lesion. 

The primary lesions of the skin are the macule, the 
papule, the tubercle, the vesicle, the pustule, the bulla, 
the wheal, and the tumor. The secondary lesions of the 
skin are the crust, the scale, the excoriation, the fissure, 
the ulcer, and the cicatrix. These may be graphically 
represented, following Piffard. 1 

Primary Lesions. A macule is a spot or stain of the 
skin which is not raised above its surface. It may be of 
any size from that of a pin-point to that of the palm of the 
hand, or larger. Large-sized and diffused, non-elevated 
lesions are usually spoken of as patches. A macule is 
usually round, but may be of any shape. It may be white, 
red, brown, black, blue, pink, or yellow, according to its 
cause. It may be due to hyperemia, as in erythema sim- 
plex ; to a change in the pigmentation of the skin, as in 

1 Cutaneous Memoranda. Wood, N. Y., 1885. 



30 



GENERAL CONSIDERATIONS. 



lentigo and chloasma, where there is increase of pigmen- 
tation, or in vitiligo, where there is decrease of pigmenta- 
tion ; to a hemorrhage into the skin, as in purpura ; to a 
development of bloodvessels in the skin, as in nsevus 
vascularis and telangiectasis ; to a parasitic growth in the 
skin, as in chromophytosis ; to a change in the consis- 
tency of the skin, as in morphoea and xanthoma ; or to 



Macule- 



Papule 



Tubercle 



Vesicle- 



Pustule - 



Bulla- 



Wheal 



'IG. 3. 


Fig. 4. 


LESIONS OF THE SKIN. 




Primary. 


Secondary. 




Crust 



Scale- 



V_^ 



A 



Excoriation 



k mssm 



Fissure- 



Ulcer- 



Cicatrix- 



V V 



XXX 



Tumor 




the introduction of foreign matter as in powder stains or 
tatoo marks. 

The macule may be evanescent or permanent; may 
remain as a macule during its existence, or may give 
place to a papule, vesicle, or pustule. It is the simplest 
of all the lesions of the skin, and is met with as a 
primary lesion in many of its diseases. 

The principal macular diseases are chloasma, chromo- 



DIAGNOSIS. 31 

phytosis, erythema simplex, lentigo, melasma, morphoea, 
nsevus simplex and spilus, purpura, scleroderma, vitiligo, 
and xanthoma. 

A papule is a circumscribed, solid elevation of the 
skin. In size it varies from that of a pin-point to that 
of a split pea. It may be of different colors, from 
white as in milium, to black as in melanotic sarcoma, but 
is usually some shade of red. It is soft or firm to the 
touch. In form it may be acuminated, rounded, flattened, 
or umbilicated. Its base may be round, oval, or angular. 
It may be due to inflammation, as in eczema ; to hyper- 
trophy of normal structures, as in verruca; to the heap- 
ing up of epidermic cells about a hair follicle, as in 
keratosis pilaris ; or to the retention of sebaceous matter 
in a follicle, as in comedo and milium. 

The papule may remain as such throughout its course, 
and finally be absorbed ; or it may change into a vesicle 
or pustule ; or it may soften and break down. 

Papular diseases have received the name of lichenoid 
diseases, and at one time we had a goodly number of 
lichens. Most of these have now been placed under 
other headings, as it is recognized that they are but single 
manifestations of other diseases. Papular diseases are 
apt to be scaly and itchy. 

The principal papular diseases are: lichen tropicus, 
linchen ruber acuminatus and planus, lichen scrofuloso- 
rum, lichen pilaris or keratosis pilaris, lichen urticatus or 
papular urticaria, acne, comedo, milium, prurigo, and 
psoriasis. Like the macule, the papule is found in many 
diseases that can not be classed as papular. 

A tubercle or nodule may be thought of as a large 
papule. Like it, it is a circumscribed solid elevation of 
the skin, usually of a reddish color. Indeed, the differ- 
ence between a papule and a tubercle is mainly arbitrary 
and for convenience. Thus, we speak of a solid lesion 
up to the size of a split pea as a papule, while above that 
it is spoken of as a tubercle. Some lesions which are 
usually spoken of as tubercles, such as the tubercular 



32 GENERAL CONSIDERATIONS. 

syphilide, may not be larger than a split pea. Stelwagon 
makes the good suggestion that " a papule may be a solid 
lesion extending upward ; a tubercle a solid lesion pro- 
jecting both upward and downward." Quite commonly, 
when a lesion is larger than a cherry it is spoken of as a 
node. Auspitz 1 makes the distinction between a papule 
and tubercle on more scientific grounds, and regards a 
tubercle as a cell-infiltration into the corium. A tubercle 
is not only larger than a papule, but it extends deeper 
into the skin. In form and color a tubercle corresponds 
to a papule. 

Tubercles may be absorbed and disappear and leave no 
trace; or they may break down and ulcerate and leave 
scars, as in syphilis; or they may remain unchanged for 
an indefinite period, as in molluscum. 

The principal tubercular diseases are : carbuncle, epithe- 
lioma, keloid, lupus vulgaris, molluscum, rhinoscleroma, 
and xanthoma. Tubercles form a very prominent symp- 
tom in leprosy, syphilis, and erythema multiforme. Of 
course, tubercular used in this sense has nothing to do 
with the tubercle of tuberculosis. 

A vesicle is a circumscribed elevation of the epidermis 
that contains fluid, generally serous. In size it varies 
from that of a pin point to that of a split pea. It may 
be unilocular, or multilocular. Its color is crystalline 
when only serum is present, more or less opaque and 
yellowish when the serum is mixed with pus, and of a 
reddish hue when blood is effused into it. It may be 
pointed, rounded, flattened, or umbilicated. Vesicles 
are in most cases due to inflammation, as in eczema. 
They may be due to simple serous effusion, as in 
erythema ; or to the retention of sweat, as in sudamina. 
They have around them, in many cases, a red halo. As 
a rule, vesicles are superficial elevations of the epidermis, 
and readily rupture and pour out their contents upon the 
skin, forming a yellowish crust. They may be below the 

1 Ziemssen's Handbuch der Hautkronkheiten. 



DIAGNOSIS. 33 

mucous layer of the skin. They may remain as vesicles, 
and dry up, their contents being absorbed ; or they may 
become changed into pastules. 

The principal vesicular diseases are : dermatitis venen- 
ata, dysidrosis, eczema, herpes, hidrocystoma, impetigo 
contagiosa, sudamina, varicella, and zoster. 

A pustule is a circumscribed elevation of the epidermis 
containing pus. In size and shape it corresponds to the 
vesicle, though the term pustule is applied to lesions up 
to the size of the finger nail. Its color is yellow and 
opaque ; or brown or reddish if there is an admixture of 
blood with the pus. It either originates as a pustule or 
develops from a vesicle or papule. It may be superficial 
or deep seated. As a rule, pustules are inflammatory, 
and when they appear as a general eruption, as in syphilis, 
they indicate a strumous or broken-down condition. 
Around each pustule there is very commonly a well- 
marked inflammatory areola. 

Pustules are prone to break down and discharge their 
contents upon the skin, forming a greenish crust. If 
located deep in the skin, they may leave scars. 

The principal pustular diseases are acne vulgaris, ec- 
thyma, furunculosis, impetigo, and sycosis. Eczema, 
syphilis, and a few other dermatoses are often markedly 
pustular in character. Pustular diseases are often spoken 
of as impetiginous. 

A bulla, or bleb, may be considered as a large vesicle 
or pustule. It is of irregular oval shape or umbilicated. 
It may be as large as a split pea, or reach the size of a 
goose egg. It rises from the skin with a slight areola or 
with none at all. It is either fully distended or flaccid, 
and does not rupture readily. It may be a bulla from 
the beginning, as in pemphigus ; or it may be formed by 
the coalescence of two or more vesicles ; or it may arise 
on an erythematous lesion, as in erythema multiforme. 
Its contents is usually serum, but it may change in time 
to pus. 

The only purely bullous disease is pemphigus; but 



34 GENERAL CONSIDERATIONS. 

bullae are met with in dermatitis, dermatitis herpetiformis, 
erysipelas, erythema multiforme, impetigo contagiosa, 
leprosy, and syphilis. 

A wheal is an evanescent round, oval, or elongated flat 
elevation of the skin, of a pinkish or white color, which 
is more or less firm to the touch. It is surrounded by a 
red halo. It may be as small as the head of a pin or as 
large as the palm of the hand. Wheals appear suddenly 
and disappear within a few hours. They are due to a 
spasm of the capillaries of a limited area of the skin and 
an effusion of serum into the meshes of the skin, the 
raised part being the site of the effused fluid, and the 
halo the congested vessels in the neighborhood. The 
whiteness of the wheal is due to the sudden effusion of 
the serum squeezing out the blood of the area. As the 
circulation becomes reestablished the serum is absorbed, 
the whiteness changing to pink, and then to the normal 
color of the skin. The disease in which wheals are met 
with is urticaria. They can also be produced by contact 
with the stinging-nettle, or by sharp traumatism on skins 
predisposed to urticaria. 

A tumor is a new growth in the skin which projects 
more or less above its surface and dips down into the 
subcutaneous tissue. It may be pedunculated. Tumors 
vary greatly in size. Their color is often that of the 
surrounding skin, but they may be red. They may be 
firm to the touch, or soft, or elastic. They may become 
ulcerated. A tumor is rather a surgical than a dermato- 
logical lesion. Epithelioma, fibroma, and sarcoma are 
types of tumors. 

Secondary Lesions. The secondary lesions of the 
skin require a much less extended description. The 
main distinction to be retained in the student's mind L 
that between a crust and a scale. This can be readily 
done if it is remembered that a crust is formed by the 
drying of some secretion or exudation upon the skin : 
while a scale is a dry, laminated mass of epidermis which 
has separated from the tissues below, the product of 



DIAGNOSIS 35 

imperfect or perverted nutrition. Thus, in vesicular 
eczema when the exudation dries on the skin we have a 
yelloAvish crust ; while in squamous eczema we have thin 
scales, the horny layer of the skin not being perfectly 
produced. Crusts are yellow when formed of dried 
serum, green when derived from pus, and black when 
there has been an admixture of blood. Scales are whitish, 
grayish, yellowish, or dirty yellow. 

Crusts are especially characteristic of ecthyma, some 
forms of eczema, favus, impetigo, and seborrhcea. 

Scales are specially abundant in dermatitis exfoliativa, 
pityriasis simplex, pityriasis rubra pilaris, psoriasis, ich- 
thyosis, and some of the lichens. 

Excoriations are familiar as scratch-marks. They are 
superficial denudations of the skin. They are of value 
as a sign of itching, as scratching is their chief, though 
not sole, cause. They frequently are followed by pig- 
mentation, if the irritation causing the scratching is long 
continued. They also occur as the natural result of some 
diseases, such as pemphigus, without the intervention of 
scratching. 

Fissures are cracks in the epidermis extending down to 
the corium. They are usually located in the folds of the 
skin, as over the joints. They may occur about the cor- 
ners of the mouth, and about the anus. They occur in 
diseases attended by infiltration and thickening of the 
skin by which its elasticity is interfered with, and are 
especially seen in eczema, psoriasis, and syphilis. They 
often bleed, aud sometimes are very painful. 

Ulcers are irregularly shaped and sized losses of 
substance. They may be quite small or of very large 
size. They may be shallow, deep, excavated, or scooped 
out. Their edges may be undermined, as in tuberculosis ; 
everted, as in epithelioma ; or sharp-cut, " punched out," as 
in syphilis. Their secretion may be scanty or abundant. 
They result either from some previous lesion or from 
injury. They occur in carbuncle, chancre, chancroid, 
ecthyma, varicose eczema, epithelioma, furuncle, lupus 



36 GENERAL CONSIDERATIONS. 

vulgaris sarcoma, syphilis, tuberculosis, and sometimes 
after zoster, dermatitis, and some pustular eruptions. 
They always heal with a cicatrix, leaving a scar. 

Cicatrices, or scars, represent an effort of Nature to heal 
a damage to the skin by means of connective tissue. They 
occur only when the papillary layer of the skin or the parts 
beneath are destroyed. They may be depressed, as in 
smallpox ; raised and puckered, as in lupus ; smooth and 
white, as in syphilis. While ulceration usually precedes 
them, they occur independently of it, as in leprosy, sclero- 
derma, and, atrophoderma. 

Other Elements of Diagnosis. Having mastered 
the lesions of the skin, we are now prepared to study the 
other elements of diagnosis. We must observe the loca- 
tion, distribution, and configuration of the eruption, and 
note its color, and whether or not it itches. When we 
have done all this, and have come to a probable conclusion 
as to the disease before us, then is the proper time to ask 
the patient a few questions as to his sensations and the 
duration of the attack. In a few cases of doubtful diag- 
nosis the microscope will aid us. 

Location. In the following lists those diseases are 
mentioned that occur especially in the region named, or 
with special frequency. In general eruptions, of course 
all regions are more or less involved. 

Upon the face we meet with acne, adenoma sebaceum, 
comedo, chloasma, dermatitis venenata, erythematous ec- 
zema, epithelioma, erysipelas, herpes febrilis, hidrocy- 
stoma, impetigo contagiosa, lupus vulgaris and erythema- 
tosus, milium, nsevus, rhinoscleroma, rosacea, sycosis, and 
xanthoma. 

An eruption confined to the middle third of the face, 
from above downward — forehead, nose, and chin — is in 
all probability rosacea. 

An eruption occupying the bearded portion of the face, 
above a line drawn from the angle of the mouth to the 
angle of the jaw, is probably sycosis. Should it occupy 



DIAGNOSIS. 37 

the bearded portion of the face below that line it is prob- 
ably trichophytosis barbae. 

If a scaly patch is found in front of the ear, it should 
put us on the lookout for psoriasis, which will often be 
found elsewhere on the body. This point may be useful 
in the diagnosis of a doubtful case. If a raw, or cracked, 
or scaly place is found behind the ear, it points to eczema. 

Upon the scalp we meet with alopecia, alopecia areata, 
dermatitis seborrheica, eczema, favus, pediculosis capil- 
litii, seborrhoea, and trichophytosis. 

If we find a patch of pustular eczema upon the back of 
the head and about the nape of the neck, the case is prob- 
ably one of pediculosis; and if we look for the nits, we 
shall find them either at the site of the eruption or over 
the parietal region. 

The chest is the favorite location for chromophytosis and 
keloid. 

Upon the bach we meet with acne, carbuncle, and the 
scratch-marks due to the irritation from pediculi. If 
we find long, parallel scratch-marks over the shoulder- 
blades, they are very good evidence of pediculi in the 
clothing. 

The extensor surfaces of the forearms and wrists are the 
favorite sites of erythema multiforme and ichthyosis, 
while the flexor surfaces give lodgement to lichen planus 
and scabies. The posterior surface of the elbow is a 
common location for psoriasis, while on the soft skin of 
the bend of the elbow we find eczema. 

Upon the hands occur callositas, dermatitis venenata 
and repens, erysipeloid, pernio, and pompholyx. 

Upon the legs ecthyma, elephantiasis, erythema exudati- 
vum, ichthyosis, purpura, and ulcers are apt to occur. 

A general eruption, that is one that is scattered over 
the whole skin, is either one of the exanthematous fevers, 
dermatitis exfoliativa, eczema, erythema, ichthyosis, 
lichen planus, lichen ruber acuminatus, mycosis fung- 
oides, pityriasis rubra pilaris, psoriasis, scabies, or syphilis. 

Of these, syphilis is most marked on the sides of the 



38 GENERAL CONSIDERATIONS. 

chest and abdomen, and upon the face along the margin 
of the hair. It may also be given as a general rule, to 
to which there are many exceptions, that syphilis occu- 
pies the flexor surfaces of the extremities and the ante- 
rior plane of the trunk, while psoriasis is found most 
markedly upon the extensor surfaces of the extremities 
and the posterior plane of the trunk. 

A universal eruption, that is one in which the whole 
skin is involved, is either eczema, dermatitis exfoliativa, 
erythema scarlatiniforme, ichthyosis, pityriasis rubra 
pilaris, or psoriasis. 

Configuration. Certain diseases assume certain config- 
urations, which, if noted, will sometimes assist in diagno- 
sis. Thus we have : 

The circular outline and scalloped border of syphilis. 

The round and bald patch of trichophytosis and alopecia 
areata. 

The map-like border of psoriasis. 

The oval or egg-shaped lesions of erythema nodosum 
and the gumma of syphilis. 

The angular, umbilicated, flattened papules of lichen 
planus. 

The annular arrangement in herpes iris and pityriasis 
rosea, and in some cases of ringworm, psoriasis, syphilis, 
and dermatitis seborrhoica. 

The patches of grouped vesicles upon reddened bases 
located over the course of a cutaneous nerve in zoster. 

The Differential Diagnosis of Ringed Erup- 
tions. 1 The eruptions that appear, either habitually or 
occasionally, in ring shape are trichophytosis corposis, 
syphilis, psoriasis, erythema multiforme, dermatitis sebor- 
rhoica, pityriasis maculata et circinata, and, rarely, favus 
of the body in its so-called herpetic stage. 

It must be clearly understood at the outset what is 
meant by an annular or ringed eruption. It is one that 
has a well-defined raised border surrounding a patch of 

1 American Medico-Surgical Bulletin. 



DIAGNOSIS. 39 

skin that is normal or nearly so, or in which active dis- 
ease has ceased. A circular patch, such as is seen in 
alopecia areata, is not a ringed eruption, as it does not 
present a well-defined raised border, and the whole patch 
is equally affected. 

Trichophytosis, or ringworm, may be taken as the type 
of ringed eruptions. In ringworm we have a well- 
defined, slightly raised border composed either of vesicles, 
rarely seen, or pustules, or papules that are slightly 
scaly, or of small crusts, the remnants of the vesicles or 
pustules. Inside of this ring the skin may show no 
change, or be slightly scaly, the scaliness diminishing 
toward the centre. The eruption usually itches slightly. 
There may be only one patch, or several in different 
stages of development. If there is any doubt about the 
diagnosis, it will readily be cleared away by examining 
some of the scales under the microscope, when if it be 
trichophytosis the fungus will be found with ease. 

This form of ringed eruption differs from syphilis: in 
itching ; in having a narrow border made up of scales, 
vesicles, pustules, or crusts ; in its scaly centre ; in being 
superficial, and in microscopical characters. It differs 
from psoriasis: in its superficial character; in its border 
not being covered with silvery scales ; in not being a gen- 
eral eruption ; in its parasite, and in not being of a pink- 
ish-red color. It differs from erythema: in not being a 
symmetrical eruption ; in its narrow border ; in its color, 
that cannot be made to disappear under pressure, and in 
having a fungous growth as its cause. It lacks the greasy 
character of dermatitis seborrhoica, and differs from the 
latter also in the presence of the trichophyton fungus. It 
differs from pityriasis rosea: in not being a general erup- 
tion; in its centre being slightly grayish, and not of the 
appearance of chamois leather, and in being parasitic. 

Syphilis at times shows itself in rings. These have one 
striking negative character, and that is, that they do not 
itch nor burn. All the other ringed eruptions either itch 
or burn to a greater or less degree. Syphilis has a well- 



40 GENERAL CONSIDERATIONS. 

marked, rather broad, slightly elevated border, which is 
infiltrated, raw-ham colored, and composed of either 
scaling papules or of nodules. The centre of the ring 
may be normal, scaly, crusted, superficially or deeply 
cicatrized, reddened or pigmented. Sometimes the nodules 
of the border may break down and ulcerate. Occurring 
on the palms or soles, the border may be hardly, if at all, 
elevated, but simply red and scaly. This is due to the 
thickness of the epidermis in these regions. It is quite 
characteristic of the annular syphilide that it is often an 
incomplete ring, the border being broken at some point. 
The diagnosis will be aided by finding other evidences of 
syphilis, which usually are to be found. This form of 
ringed eruption differs from ringworm in the way already 
indicated. As it is quite possible for a syphilitic subject 
to have any of the other ringed eruptions, a history of 
the case will sometimes be unreliable, if depended on for 
diagnosis. It is, therefore, better to make the diagnosis 
solely on what we see. It is only in very doubtful cases 
that a history of the eruption is desirable to help us to 
decide aright, and then only after a careful weighing of 
the evidence. A ringed syphilide is most apt to be con- 
founded with psoriasis, but it differs from it : in having 
a raw-ham, and not a pinkish-red color; in not itching; 
in showing a red seam beyond the scales ; in the scales 
being less silvery, smaller, and more abundant; in the 
border formed of individual lesions ; in not being so gen- 
erally distributed over the body, and in not occurring 
in the characteristic sites of psoriasis — that is, on the 
elbows and knees. If the case were psoriasis, there 
would surely be some characteristic patches to guide us. 
Erythema multiforme and syphilis are so unlike in every 
respect that it is hardly possible they could be confounded. 
Dermatitis seborrhoica is located on the chest and between 
the shoulder-blades, and will be found at the same time 
on the scalp. These locations are not characteristic of 
syphilis. Moreover, syphilis lacks the greasy feel of 
seborrheal dermatitis, and has a raw-ham color which is 



DIAGNOSIS. 41 

never seen in the latter. Pityriasis rosea is readily dis- 
tinguished from syphilis by the occurrenee at the same 
time of both macules and rings, by its lighter color, and 
by the chamois-leather look of the contents of the rings. 
The infiltrated border of the syphilide distinguishes it 
from all the other ringed eruptions. 

When psoriasis forms rings it does so by the clearing 
up of the centres of old patches, and there will be char- 
acteristic patches of psoriasis to guide us in diagnosis. 
The border of the ring is usually quite broad and slightly, 
if at all, thickened ; its color is the pinkish-red of psoria- 
sis, and the scales that cover it are large and silvery. 
The centre of the ring is composed of normal skin, which 
may be a little red. The scaling will be seen to be com- 
mensurate with the redness. The disease is commonly 
itchy. 

The differential diagnosis from syphilis and ringworm 
has been given above. Like the syphilide, psoriasis bears 
no resemblance to erythema except in its ring shape. 
From dermatitis seborrhoica it differs in not being greasy 
and in its silvery scales. At times the two diseases do 
bear a close resemblance to each other, but even then it 
will usually be easy to find some typical lesions of one 
or the other disease to decide the matter. There is little 
likelihood of confounding psoriasis with pityriasis rosea, 
as the former is much less superficial than the latter, and 
its scales are large and silvery, and not small and adher- 
ent ; besides, it lacks the chamois-leather color which is 
a marked feature of pityriasis rosea. 

Erythema multiforme, or erythema exudativum, not 
infrequently forms rings by the absorption of the centres 
of large tubercular lesions or patches. It is easy to 
recognize the lesion, as there will be other and character- 
istic erythematous lesions to guide us. The border of 
the ring is raised and its color is red, the redness, as in 
all erythematous lesions, being readily made to disappear 
on pressure, to return promptly when the pressure is 
removed. When the lesion has lasted for some time the 



42 GENERAL CONSIDERATIONS. 

color becomes darker and cannot so readily be made to 
disappear, because now the coloring-matter of the blood 
remains behind in the tissues. The centre of the ring 
is red or discolored on account of the partially absorbed 
exudate. Another form of ringed erythema is what is 
known as erythema, or herpes, iris, in which we have 
either a purplish spot surrounded by a raised whitish 
ring containing fluid, and outside of this a red areola ; 
or a vesicle in the centre with a purplish zone about it, 
a raised whitish ring containing fluid, and a red areola 
outside of all ; or a central bulla with one or two rings 
of vesicles about it. This form of erythema is usually 
symmetrical and occurs upon the extensor surfaces of the 
arms and legs and upon the backs of the hands and feet. 
It may occur as part of a general erythema multiforme 
or by itself. The ringed erythema is so peculiar in its 
features as to offer little difficulty in differential diagnosis, 
and need not detain us further. 

Dermatitis seborrhoica or eczema seborrhoicum, is the 
lichen annulatus of Wilson and the seborrhoea corporis of 
Duhring. It forms ring-shaped lesions on both the scalp 
and trunk. These are best and most often seen on the trunk, 
but may also be found on the limbs. Their favorite sites 
are the chest and the back between the shoulder-blades. 
The rings are of large and small size, and at the same 
time there will be found fatty plates with more or less 
redness, the usual lesions of seborrhoea sicca. The border 
of the ring may be broad or narrow. If the former, 
then it will be formed of greasy crusts upon a reddened 
base ; if the latter, the border will be seen to be made up 
of a number of red points, the open mouths of the folli- 
cles of the skin ; or the border may be narrow and yet 
made up of fatty crusts. The skin in the neighborhood 
is commonly greasy, and the enclosed area of skin will 
look as if varnished, being glazed and yellow. 

The differential diagnosis from ringworm, syphilis, and 
psoriasis has been given already. The greatest difficulty 
is often found in the diagnosis from pityriasis rosea, 



DIAGNOSIS. 43 

especially when the ringed lesions are on the legs. The 
resemblance is then so great that it has led some to ques- 
tion if seborrheal dermatitis and pityriasis are not iden- 
tical. As a rule, the seborrheal lesion is more fatty and 
yellow, while that of pityriasis is more scaly, and the 
contained skin is more wrinkled and chamois-leather- 
looking. In typical cases there will be no difficulty in 
the diagnosis if the characteristics of both diseases are 
borne in mind. The presence of a seborrhea on the 
scalp is corroborative evidence of the seborrheal nature 
of a doubtful eruption. 

Pityriasis rosea, or pityriasis maculata et circinata, not 
only shows rings, but also, as its name indicates, macules, 
and both forms of lesions are always present at the same 
time. It can easily be seen that the primary lesion is a 
pale-red papule, increasing in size, to become later a rosy- 
red lesion, which, after attaining a certain size, clears up 
in the centre, so as to form a ring with a pale-red border 
and a yellow, old-parchment, or chamois-leather-like cen- 
tre. Both the borders and inclosed areas are slightly 
scaly. It is usually most pronounced on the chest and 
shoulders, but it may be a general eruption, although the 
hands, feet, and face are rarely affected. Its differential 
diagnosis has been given under the previously described 
diseases. 

It is a property of all these eruptions that, if two or 
more of their rings appear near each other, they are very 
apt to run together and form figure-of-eight or gyrate 
lesions from the disappearance of the borders at the part 
where contact has taken place. 

The ring-shaped or herpetic form of favus is not com- 
monly seen. It occurs in favus of the body. It will 
then bear so strong a resemblance to ringworm that at 
first it is impossible to distinguish which it is ; but it is 
only necessary to wait a short time, when a well-marked 
favic cup will develop. 

Lichen planus papules, when they have crowded together 
into a patch, will form rings at times by the absorption of 



44 GENERAL CONSIDERATIONS. 

the central papules. The ring is rarely of large size ; its 
color is the peculiar violaceous color of lichen planus; 
the centre is depressed and the whole is scaly. As these 
rings are never seen apart from the simultaneous occur- 
rence of characteristic flat, angular, smooth papules, with 
central umbilication, there is no possibility of confusing 
them with those of the other ringed eruptions. 

We occasionally see rings in lupus erythematosus and 
in epithelioma, but such occurrences are exceptional. 
When they do occur the other signs of the one or the 
other disease will be so much in evidence that there will 
be little danger of mistake in diagnosis. 

Lupus erythematosus has a peculiar red color ; its border 
is usually covered with closely adherent scales, and the 
ring will have a cicatricial centre. At the same time 
there will be other patches present of typical lupus ery- 
thematosus. 

Epithelioma, even when it does form a ring, has that 
characteristic hard, raised, waxy border which we see in 
all epitheliomas of the skin, and commonly presents an 
ulcerated surface inside of the ring, which will be enough 
for diagnosis. 

Color. An eye for color is of some value in diagnosis. 
It is very difficult to convey by words a correct idea of 
the color of an eruption, but perhaps this list may prove 
helpful : 

Raw ham of syphilis. 

Brilliant red of erysipelas. 

Inflammatory red of eczema. 

Dark red of purpura. 

Bright red of psoriasis. 

Brown of pigmentary diseases. 

Yellowish or cafe" au lait of chromophytosis. 

Sulphur yellow of favus. 

Buff of xanthoma. 

Violaceous or dull red of lichen planus and lupus 
erythematosus. 

White of leucoderma. 



DIAGNOSIS. 45 

History. Having carefully noted all these objective 
symptoms, now is the time to obtain the history of the 
case, either for the purpose of scientific study of its 
etiology and natural course, or for the purpose of clearing 
up some doubt as to the diagnosis. It is so easy to obtain 
a history of syphilis that were we influenced by the his- 
tory we would be often misled. There is no reason why 
a patient with syphilis should not have any other skin 
disease. Moreover, most people do not pay much atten- 
tion to the course of their diseases, and it would be 
difficult for them to give a correct account of them if 
they would. Of course, a clear history of the initial 
lesion of syphilis, or its presence, would clear up any 
doubt as to an erythematous rash. The history of a 
scaly disease recurring at frequent intervals upon the 
elbows and knees would go far to determine the existence 
of psoriasis. In urticaria we often have to rely upon the 
statement of the patient or attendant as to the appear- 
ance of the wheals, as their presence at some time is 
pathognomonic, and they are usually absent when we see 
the patient. In these and similar ways the history is 
useful, but it should be entirely subordinated to the study 
of the objective symptoms. 

Pruritus. It is important to know whether a dis- 
ease itches or not. This we can discover by the pre- 
sence or absence of scratched papules or scratch-marks. 
The itching eruptions are dermatitis herpetiformis, ec- 
zema, pediculosis, prurigo, pruritus cutaneus, scabies, and 
urticaria. The symptom is also present in the lichens, 
psoriasis, dermatitis seborrhoica and trichophytosis. It 
is markedly absent in syphilis, although an occasional 
case of syphilis will be encountered in which there is 
itching. 

Burxixg. The sensation of burning is one the exist- 
ence of which we must take upon the patient 's statement. 
It is a prominent symptom in erythema. Very often a 
patient will say that his eruption itches, but if you watch 
him he will soon begin to rub his skin gently with the 



46 GENERAL CONSIDERATIONS. 

heel of his hand. This indicates that the sensation is one 
of burning and not of itching. In itching, the nails are 
used, or else the rubbing is vigorous. 

Pain. Another symptom for the establishment of 
which we have to rely upon the patient is that of pain. 
The vast majority of skin diseases, while they may cause 
more or less discomfort, are not painful ; but sharp neu- 
ralgic pain is a prominent symptom in zoster, and oc- 
casionally in epithelioma. The presence of pain of a 
shooting character will be one point in the differential 
diagnosis between lupus and epithelioma, and in favor of 
the latter. We also meet with pain in neuroma, derma- 
talgia, and in some forms of leprosy. 

Microscope. The principal use of the microscope in 
the hands of the general practitioner is, as far as derma- 
tological diagnosis is concerned, the determination of the 
presence or absence of fungi in hair and scales in a doubt- 
ful case of ringworm, favus, chromophytosis, or other 
parasitic disease. Happily, as between favus and ring- 
worm we seldom have need of the microscope for diag- 
nosis, their symptoms being so pronouncedly different. 
In the hands of the skilled pathologist and bacteriologist 
the microscope is constantly adding to our knowledge of 
diseases of the skin and is of great value. 

Method op Examination of Patients. They 
should be always examined by day-light or by electric light. 
It is prudent to refuse to give an opinion of a case when 
seen in a poor light or by artificial light. If the patient 
is a man, it is necessary to request him to strip from 
top to toe, if there is the slightest need of seeing more 
than the ordinarily exposed parts. In the case of a woman 
such an inspection can seldom be made. The same end 
can be attained by exposing one part after another. In 
all cases we are justified in refusing to treat a case that 
we have not been given ample opportunity to examine. 

All examinations of patients should be made in a warm 
room. The contact of cold with the usually covered skin 
is apt to give it a mottled look that obscures the diagnosis. 



THERAPEUTIC NOTES. 47 

It is well never to give a diagnosis of an obscure case 
that is under local or constitutional treatment until all 
treatment has been suspended for a few days and the dis- 
ease allowed to assume its natural appearance. 

Under the name of diaskop, Unna has recommended 
the use of a small piece of thick, clear glass, marked with 
a measuring-scale, for the purpose of exercising pressure 
upon the skin under examination. This does away with 
the confusing redness, brings into greater prominence ana- 
tomical lesions, and enables us to take accurate measure- 
ments of them. 

Every patient should be regarded as possibly out of 
health in some way quite apart from his skin trouble, 
and examined as to the performance of all his bodily 
functions quite as carefully as if he had come to us only 
for the treatment of some internal disorder. 

Therapeutic Notes. 

In the second part of this book will be found the treat- 
ment suitable to the various diseases. In this place my 
object is to give the reader a few notes upon some of the 
newer and comparatively unknown remedies for skin 
diseases. 

Plaster-muslins were devised by Unna. They are 
made by spreading upon muslin a mixture of gutta percha 
and oleate of alum. With the plaster mass many drugs 
may be combined. Salve-muslins we owe also to Unna. 
They consist of a salve mass composed of benzoated mut- 
ton tallow and Avax, with which various drugs are com- 
bined. The muslin is dipped into the melted mass, then 
dried and rolled flat and smooth, either on one or both 
sides. Machinery is used for the purpose. 

Salve pencils and paste pencils we owe to Unna. The 
former are composed of wax and olive oil moulded into 
sticks about the size of the little finger. The latter 
are made of starch, tragacanth, or gum arabic, with 
which the drug is incorporated into sticks about the size 



48 GENERAL CONSIDERATIONS. 

of a slate pencil. Neither form of pencil has come into 
general use. 

Gelatin preparations, one of which is given in the for- 
mulary, were introduced as preferable to ointments, and 
many German and English authorities speak well of 
them. They are troublesome to apply because they have 
to be heated before being used. They have not become 
popular in this country. The best one, in my experience, 
is that devised by Unna, made of oxide of zinc, 30. ; 
gelatin, 30.; glycerin, 39.; and water, 10. This when 
cold forms a solid mass like white rubber. It is best 
used by heating it in a double saucepan like that used 
for cooking oatmeal. When warm it is to be spread on 
with a wide painter's brush. Immediately over the layer 
thus formed is placed a layer of absorbent cotton and 
then a roller bandage. It is excellent in subacute and 
chronic eczema. 

Under the name of skin splints Unna and Engman 1 
have introduced a method of applying dressings in skin 
diseases that is certainly ingenious. Pressure is often 
wanted. It should be even. It is also desirable that such 
dressings should be durable, not readily dislodged, and 
easily removed and replaced. For this purpose the part 
to be dressed is first covered with a layer of plaster- or 
salve-muslin, or simple bandage-muslin. This is painted 
over with a preparation composed of gelatin and glycerin, 
of each 15 parts; water, 40 parts; and oxide of zinc, 30 
parts. When this is set it is painted over with a 10 per 
cent, solution of chromic acicl, the green color of which 
may be masked by applying a varnish of zinc oxide and 
shellac. If a hairy part is to be dressed, and it cannot 
be shaved, the hairs should be greased. To remove the 
dressings it is only necessary to raise the edge and to 
touch the under side of the plaster with absorbent cotton 
wet with benzine. Variously medicated salve- or plaster- 
muslins are to be used according to the nature of the 
case. 

1 Monatshefte f. prakt. Dermat, 1893, xvii., p. 481. 



THERAPEUTIC NOTES. 49 

George H. Fox 1 has brought out a series of elastic web- 
bing, broad rings of various sizes, that are admirable for 
retaining dressings in place. They serve the purpose of 
Unna's skin splints without any trouble either to the 
patient or physician. 

In 1891 two excellent excipients were brought to our 
notice : one that is made from gum tragacanth, and called 
bassorin; and one that is made from Irish moss, and 
called plasmmt. They both sink well into the skin, leav- 
ing a protective film on it that can be readily removed 
with water. A more recent excipient of this class is called 
gelanthum. It is composed of gelatin and tragacanth. 

Medicated soaps, especially those containing an excess 
of fat, have been brought out in great variety during the 
past years, and possess certain virtues, though as a rule a 
soap is not the best vehicle for medication. They are 
cleanly, can be readily removed from the skin with water, 
and can be made to produce a greater or less effect accord- 
ing to whether the lather is allowed to remain or not. 

Soap Pomade 2 is made of: 



Lard, 


3iss., 


50. 


Potash, 


^ivss., 


17.50. 


Distilled water, 


3ivss., 


150 



The potash is to be dissolved in 100 cc. (£iij. 5hj.) of 
the water. The rest of the water and the lard are to be 
mixed in a water bath, and the potash added little by 
little with stirring. At the end of half an hour 10 cc. 
(oiiss.) of alcohol is to be added, aud the whole concen- 
trated by heat to the consistence of soft soap. AVhen 
the alcohol has evaporated, 20 grammes (5v.) of lanolin 
is to be stirred into the mass in small fragments. The 
whole is then to be evaporated to 120 grammes (§iv.), 
poured into a cold mortar, and whipped constantly with 
the pestal until completely cold. It is to be kept in a 

1 New York Med. Journ., 1895, lxii., p. 594. 

2 Annals, derm. et. syph., 1907, viii., 454. 



50 GENERAL CONSIDERATIONS. 

closed jar. Most drugs mix well with this, excepting 
mercury, iodide of potash, aud acids. It is commended 
for use on the scalp, as it can be applied like a pomade 
in the evening and readily washed oif in the morning. 
If a more prolonged action of the medication should be 
desired, the pomade can be left on the scalp. 

Under the name of oleum physeteris or choenoceti a 
species of whale oil was recommended by Guldberg 1 as 
an excellent excipient. Althal 2 is also derived from 
whale oil, in this case the Walrat whale. It is said to 
be odorless and perfectly bland. It occurs as mother-of- 
pearl white crystals, which subjected to heat form a fatty- 
feeling mass. 

Endermol, which is described as a a stearamide with 
hydrocarbons of paraffin series," is miscible with all 
drugs, and commended as a non-greasy base for oint- 
ments. It is of light-gray color, odorless, and about the 
consistence of vaseline. 

Resorbin is a mixture of almond oil, wax, water, and a 
small amount of a solution of gelatin. It combines readily 
with fats. It is commended for its penetrating powers, 
and is said to cool the skin and allay itching and inflam- 
mation. It is used alone or as an excipient in many 
diseases of the skin. 

Myronin is a yellow, slightly aromatic, butter-like sub- 
stance, for which penetrating powers are claimed. It is 
said to be a good excipient for mercury when used for in- 
unctions and for zinc oxide in intertrigo and dry eczemas. 

Vasogen is an oxidized vaseline which occurs both as a 
solid and a fluid, and is used as an excipient for various 
drugs. 

In the way of drugs of comparatively recent date we 
have : 

Airol, a combination of bismuth, iodine, and gallic 
acid, of gray-green color, odorless and tasteless, which is 

1 Monatshefte f. prakt. Dermat., 1890, x., 437. 

2 Dermat. Zeitschrift, 1899, vi., 158. 



THERAPEUTIC NOTES. 51 

supposed to have the virtues of iodoform, though not so 
strong. It can be used as a dusting powder or as an 
ointment with vaseline. 

Alumnol is a fine white powder, non-hygroscopic, and 
stable. It is soluble in water to the extent of 45 per 
cent., forming a permanent solution. Used as a powder 
(12 to 25 per cent.), ointment (1 to 12 per cent), or in 
collodion (5 to 10 per cent.), it is recommended in acute 
and chronic eczema, various dermatitides, trichophytosis, 
chromophytosis, and contagious impetigo. 

Anthrarobin was proposed as a substitute for chrysa- 
robin, but it is a weak preparation and has not proved of 
special use. 

Anthrasol is made by the distillation of coal and the 
extraction from it of pyridin and chinolin bases. The 
product of the distillation is added to an equal amount of 
juniper tar. It occurs as an oily liquid of tarry odor. 
It is soluble in acetone, benzol, fixed oils, petrolatum, and 
to a slight extent in pure alcohol. It is commended as a 
substitute for tar, and is said to be more active and less 
irritating than that drug. It is used in the same dosage 
as is tar. 

Atoxyl is an arsenical preparation containing about 
half as much arsenic as does arsenious acid. It is said 
to be twenty times less poisonous. It is best used in the 
form of intramuscular injections in the dose of 0.2 
grammes every second day, and is said to be beneficial in 
psoriasis, lichen ruber, and xanthoma diabeticorum. 

Bromotan is a yellow, very fine powder, containing 13 
to 15 per cent, of bromin. It mixes readily with other 
powders, and may be used in ointments in 10 per cent, 
strength. The latter applied on bandages two or three 
times a day quickly cures pruritus vulvas. 

Dermatol, a subgallate of bismuth, is said not to cake 
and not to be poisonous. It is used as a powder for 
recent wounds, forming a crust under which healing takes 
place. For excoriations, intertrigo, and slightly moist 
eczema it is to be mixed with equal parts of starch. For 



52 GENERAL CONSIDERATIONS. 

large, irritable ulcers it may be used as an ointment of 10 
per cent, strength, or as a powder. 

Eigon is a combination of iodine and albumen. It 
occurs as a light-brown, tasteless, insoluble powder. It 
is used locally as a 20 per cent, powder or a 5 per cent, 
ointment in wounds and ulcers of all sorts. 

Em,ol is a soft, impalpable powder of delicate pink hue. 
It is analogous to fuller's earth. It softens hard water 
when added to it, and with warm water forms a natural 
soap, leaving the skin feeling pliable and soft. It is said 
to be a good dusting powder and to possess remarkable 
power in separating and causing to fall horny patches of 
eczema and keratosis. For this purpose it is made into 
a paste with water, and, when applied, it is covered with 
oiled silk or rubber tissue. 

Empyroform is a condensation product of formaldehyde 
and birch tar. It occurs in the form of a grayish-brown, 
flour-like powder with a very faint odor that is not that 
of tar. It is soluble in acetone, solutions of caustic alka- 
lies, and chloroform. It can be used in ointments. It is 
an antipruritic. It has been found useful in all stages of 
eczema, seborrheal eczema, psoriasis, prurigo, pityriasis 
rosea, and chromophytosis. Dosage : 1 to 5 per cent, in 
acetone or chloroform, and 5 to 25 per cent, in ointments. 

Eugallol is a dark brown liquid containing 33 J per 
cent, of acetone. Whitfield recommends it for licheni- 
fication of the skin. 

Europhen. An amorphous powder of yellow color and 
aromatic odor, containing 28 parts of iodine in 100. It is 
insoluble in water and glycerin ; readily soluble in ether, 
chloroform, collodion, and traumaticin. It is useful in 
venereal ulcers and mucous patches in pure powder or 2 
to 5 per cent, ointment : also in tertiary syphilis as hypo- 
dermic injections in the vicinity of the lesion and in solu- 
tion in oil. 

Filmogen is a solution of nitrate of cellulose in acetone 
with enough oil to make it elastic. It is used as an ex- 
cipient for salicylic acid, resorcin, iodoform, pyrogallol, 



THERAPEUTIC NOTES. 53 

bichloride of mercury, chrysarobin, tar, ichthyol, and car- 
bolic acid. It holds in suspension sulphur and zinc. 

Fuchsine, and other aniline dyes, in 1 per cent, solution 
in water, are recommended as useful in ringworm, inop- 
erable cancerous ulcers, erysipelas, and other local infec- 
tious diseases. 

Gattacetojjhenone, made by the action of acetic acid upon 
pyrogallol, was brought out in 1891 as remarkably effi- 
cient in the treatment of psoriasis. It may be used in 5 
to 10 per cent, strength in ointment or collodion, does not 
stain the clothing, and thus far has proved neither poison- 
ous nor very efficacious. 

Hydroxylamine is poisonous when absorbed. It was 
commended for psoriasis, but cannot be used over large 
surfaces. It has been commended in lupus vulgaris and 
ringworm of the scalp and beard, a grain and a half of 
the hydrochloride being dissolved in an ounce and a half 
each of alcohol and glycerin. It has not gained popular 
favor. 

Iehthalbin is a combination of ichthyol and albumen. 
It is tasteless and odorless, and usually does not disturb 
digestion. It passes through the stomach unchanged, to 
be split up in the intestinal tract. Used internally in 
doses up to 60 grains a day in rosacea, eczema, urticaria, 
and pruritus. 

Iodolen is a combination of albumen and iodine, con- 
taining 36 per cent, of the latter. It is a yellow, coarsely 
granular, tasteless and odorless, almost insoluble powder. 
It can be given by the mouth as a substitute for the iodides 
and in the same doses as potassium iodide. Externally 
it is said to be a good, imirritating antiseptic. 

Isarol is the same as ichthyol, but made from a bitu- 
minous shale found in certain parts of the Alps. 

Lenicet is an alumenium acetat in the form of a very 
fine snow-white powder, slightly soluble, a»id non-poison- 
ous. It is unaffected by light and heat, non-hygroscopic, 
and of faintly acid odor. It is suspended in water; 
more soluble in the presence of acids ; and forms soluble 



54 GENERAL CONSIDERATIONS. 

combinations in alkaline solutions. It combines with 
various drugs, and is said to be useful in hyperidrosis, 
contagious impetigo, dermatitis, and eczema. 

Liquor anthracis simplex and compositus are thin fluids 
prepared from coal tar, which are said to be non-poison- 
ous and to be useful in chromophytosis, trichophytosis, 
and chronic eczema. The compound fluid contains sul- 
phur, resorcin, and salicylic acid. 

Merged is a yellowish- white powder insoluble in water, 
a combination of cholic acid, mercury, and tannate of 
albumen. It is said not to cause intestinal disturbances, 
and to be readily absorbed, and to act well in ordinary 
cases of syphilis. Dose, 1 capsule three times a day, 
gradually increased. 

Naftalan is a dark-colored, empyreumatic, thick mass 
that comes from Armenia. It is exhibited in ointment 
in the strength of 2 \ to 5 per cent. It seems to be useful 
in all diseases in which tar is indicated, but is more dis- 
agreeable to use. 

Nosophen is a yellowish, odorless, and tasteless powder 
used as a dusting-powder in ulcers, balanitis, herpes pro- 
genitalis, and wounds. 

Oxy naphthoic acid is recommended by Schwimmer for 
scabies and prurigo in 10 per cent, strength in ointment. 
His ointment for scabies is composed of 10 parts each of 
this acid, chalk, and green soap, to 80 or 100 parts of 
lard. 

Pyraloxin is a brownish black substance made by ox- 
idizing pyrogallol by exposing it to a current of air in the 
presence of ammonia vapor. It is said to be non-toxic 
non-errosive, and to be useful in lichen planus, psoriasis, 
and sycosis. 

Sajodin is a tasteless powder which is insoluble in water 
and contains 26 per cent, of iodine. It is said not to dis- 
turb the digestion and an excellent substitute for iodide of 
potash. Dose : 1 5 grains four times a day. 

Sapolan contains 2^ per cent, of a especially distilled 
naphtha product, 1J per cent, of lanolin, and 3 to 4 per 



THERAPEUTIC NOTES. 55 

cent, of soap. It is of dark-brown color, of ointment con- 
sistency, smells slightly of naphtha, and is easily rubbed 
into the skin. It is said to be very efficacious in acute 
and chronic eczema, pruritus senilis, impetigo contagiosa, 
ecthyma, and urticaria. 

Steresol is an antiseptic varnish composed of gum lac, 
benzoin, balsam of tolu dissolved in alcohol, and a small 
amount of carbolic acid or phenol. It is recommended 
especially because it adheres to the mucous membrane as 
well as the skin, and has been found useful in various 
ulcers and chronic eczema. 

Tar. Compound tincture of coal tar is commended by 
Duhring as a substitute for liquor carbonis detergens. It 
is made by digesting 1 part of coal tar with 6 parts of 
tincture of quillaja (1 to 4 in 95 per cent, alcohol). It 
is used diluted, 1 5 minims to the ounce of water. 

Thigenol is said to be an organic compound of sulphur 
containing 10 per cent, of sulphur. It is a dark-brown 
thick liquid with a faint sulphurous odor in the container 
that is lost when it is used. It has a slight empyreumatic 
taste that is covered with peppermint water, syrup of 
orange peel, and extract of liquorice. It is soluble in 
distilled water, alcohol, glycerin, collodion, and chloro- 
form. It is an antipruritic. It has been found useful in 
acne, eczema of all forms, erysipelas, burns, impetigo, 
pernio, rosacea, scabies, seborrhoea, and sycosis, and as an 
adjuvant in favus and trichophytosis. Dosage : By the 
mouth, 3 to 10 grains three times a day in solution or 
pill. Externally, from 5 to 50 per cent, strength in 
ointments, pastes, or paints, or pure. 

Ihilanin is lanolin acted on by sulphur and containing 
3 per cent, of the latter. Recommended for acute and 
chronic eczema, and in lupus erythematosus. 

Thiolan is a combination of sulphur, indicated where- 
ever sulphur is. 

Thiosavonale is a readily soluble sulphur soap. 

Tumenol in solution with equal parts of ether, alcohol, 
and water, or glycerin, or in form of paste or ointment 



56 GENERAL CONSIDERATIONS. 

is useful iu moist eczema, burns, sycosis, ulcers aud 
rhagades. 

Xeroform is a smooth, fine, greenish-yellow, tasteless 
powder, smelling faintly of carbolic acid. It is antiseptic, 
and is said to be useful in moist eczema of the hands and 
about the anus. 

Phototherapy. Direct sunlight has long been known 
as a bactericide. In most countries the hours of sunlight 
are short and uncertain. This led Finsen of Copenha- 
gen, to introduce a method of light therapy by means of 
electric light. Further investigations have shown that 
the blue, violet, aud ultraviolet rays of the spectrum are 
bactericidal ; and that light can be made to penetrate 
the skin and cause reactive structural changes of a 
destructive nature. 

Since Finsen introduced his lamp, a number of lamps 
have been put on the market, only a few of which can be 
mentioned here. 

Finsen-light therapy is the use of electric light from 
carbon points concentrated by means of lenses upon 
the part to be treated. To render it effective the blood 
must be pressed out of the tissues. This is done by 
an attendant who presses upon the skin pieces of quartz 
in a special holder. Painting the skin with a 5 per cent, 
solution of Eosin increases the penetration of the light. 
The exposures have to be made for from half an hour to 
two hours daily until reaction sets in, and repeated when 
the reaction caused by the treatment subsides. The pro- 
cess is tedious and expensive, months and years beiog 
required for the cure of some cases. Lupus erythematosus, 
lupus vulgaris, and the tubercular diseases are those in 
which this treatment has given the most brilliant results. 
None of the substitutes for the Finsen apparatus are as 
effective as it is. Next in efficiency is the Finsen- 
Reyn lamp. 

Iron electrode lamps are also used either with or 
without a quartz lens, such as the Krohmayer and the 



THERAPEUTIC NOTES. 57 

Prffard lamp. They are more active without the lens. 
A current of 12 to 25 amperes is to be used, the lamp 
held from 2 to 5 inches from the area to be treated, 
and the exposure made from 2 to 10 minutes daily, or 
every second or third day. After a number of exposures, 
the skin may be tanned as from sun burn. This lamp 
is specially useful in alopecia areata. 

Mercury Vapor lamps are glass vacuum tubes contain- 
ing a certain amount of mercury, which is vaporized by 
passing through it a current of electricity. They are 
very rich in blue, violet and ultraviolet rays. The 
Heraus, and the Schott lamps are types of this form of 
lamp. The latter is called the " uviol " lamp. They 
have been found useful in acne, alopecia areata, dermatitis 
herpetiformis, chronic eczema, furunculosis, lupus erythe- 
matosus, prurigo, psoriasis, rosacea, and sycosis. 

Radiotherapy , or Roentgen-ray therapy is the use of an 
x-ray tube incited by a static machine or an induction 
coil. There are many kinds of tubes on the market. For 
a description of them and a discussion of the physics of 
rr-ray work, the reader must consult larger works on the 
subject. The sound tissues must be protected by covering 
them with sheets of lead ^ of an inch thick. Great 
care must be exercised lest a burn be caused. Serious 
injury has resulted to many operators from frequent 
short exposures. Various devices have been invented to 
measure the rays, but none thus far has proved very sat- 
isfactory. The best is probably, a milliampere meter 
on the secondary current, from 1 to 1J m. a. being used. 
Commonly, however, operators rely upon feeling their 
way by making at first short exposures of five minutes 
with the tube at 15 cm. distant from the skin and increas- 
ing the time and lessening the distance as they find the 
equation of the patient's skin. At first an interval of 
two weeks should elapse before a second treatment, as 
the effect of the first is sometimes long delayed. If an 
erythema is produced, a pause of two or three weeks 



58 GENERAL CONSIDERATIONS. 

must be made. More explicit directions will be given in 
the body of this book. 

Radium exerts an action similar to the Roentgen rays. 
The material is still too rare and expensive for it to come 
into common use. 

High-frequency Currents. These are electric currents 
of high potential and great frequency generated by a coil 
acting on the so-called high-frequency apparatus. The 
current is applied by means of a handle into which fits a 
vacuum glass tube of any desired shape ; or by means of 
a point of carbon fitting into the same handle ; or by the 
Piffard roller electrode. When the electrode is approached 
to the skin a violet light fills the tube, and a shower of 
sparks fall upon the skin, giving rise to a tingling sensa- 
tion. When the tube is in contact with the skin ting- 

Fig. 5. 



Piffard's Intensifying Handle. 

ling is not felt, and there are no sparks ; but the tube 
feels warm. These currents are used for stimulation, as 
in chronic eczema and alopecia ; to relieve pruritus ; and 
to destroy warts and new growths. 

Congelation. There are four agents used for freezing 
the skin for therapeutic purposes : 1. Chloride of ethyl. 
This occurs in the form of a glass bulb containing the 
liquid, which runs out into a capillary tube. When the 
bulb is held in the hand its warmth drives a fine stream 
of fluid out of the end of the tube, which soon congeals 
the part. 2. Rhigolene. This may be sprayed on the 
skin with an ordinary hand atomizer. It produces a 
temperature of 51° below zero Fahr. Though these 
two have been recommended in the treatment of lupus 
erythematosus, they are used practically only for the pro- 
duction of local anesthesia, for the opening of abscesses, 
and for taking sections of the skin for biopsies. 



THERAPEUTIC NOTES. 59 

3. Carbon dioxide. This comes in iron cylinders fur- 
nished with a stop-cock, and is familiar as a part of the 
fitting of a soda fountain. In order to use the gas the cylin- 
der should be slightly tipped up, and a piece of chamois 
skin in several thicknesses wrapped about the vent ot 
the cylinder, so as to form a little bag. The stop-cock 
is then opened carefully, and the gas allowed to escape, 
which it does with the sound of escaping steam. In a 
few moments enough snow has formed in the bag, by 
condensation, and then the stop-cock should be closed. 
The snow is moulded with the fingers into a mass which 
may be whittled to any desired size or shape. Its teni- 

Fig. 6. 




WAITE &.BAETLETT M'F"G CO. 

Piffard's Roller Electrode. 



perature is about 90° below zero, Fahr. The snow is 
simply pressed against the skin, and the depth to which 
the freezing is carried depends upon the length of the 
time it is in contact with the skin and the degree ot 
pressure which is used. Pusey has fouud that after ten 
seconds the skin is white and hard, a wheal forms in 
ten minutes, and in six to ten hours there is a circum- 
scribed area of inflammation with vesicles. A thin 
crust subsequently forms that falls without a scar. 
After twenty seconds a bulla will form in six to eight 
hours, followed by a crust that falls in ten days. After 
thirty seconds a dry eschar forms that falls in about 
three weeks without ulceration, and leaving a superficial, 
smooth, white scar. If deep destruction is desired, the 
freezing is to be repeated. 



10 



60 GENERAL CONSIDERATIONS. 

4. Liquid Air. This is atmospheric air condensed by 
special machinery under great pressure and in the pres- 
ence of cold. Its temperature is about 220° below 
zero, Fahr. It looks like water. It is dispensed in 
especially constructed glass flasks, with double sides, be- 
tween which is a vacuum. The expansion of the air is 
so great that the flask cannot be corked tightly, but with 
a loose-fitting cotton plug. The most convenient way to 
use the air is by means of a swab made by winding 
absorbent cotton on a stick. This is clipped into the 
liquid and pressed against the skin. Its action is simi- 
lar to that of carbon dioxide, but as it is twice as cold its 
effects are attained in half the time. The actual freezing 
is not very painful, but the thawing out is. The pain 
may be somewhat mitigated by the application of cold 
water. 

Congelation is the best means for the destruction of all 
sorts of nevi. In deep port wine marks it is of doubtful 
efficacy. It is one of the best methods for the treatment 
of lupus erythematosos. It may also be used for the 
destruction of warts, and small superficial epitheliomas. 

Opsonic or Vaccine Therapy. In 1902, Wright and 
Douglas, * and, in 1 904, independently of them, Neufeld 
and Rimpau, 2 found substances in the blood which act on 
bacteria so as to render them more susceptible of pha- 
gocytosis. Wright gave to these the name of opsonins, 
which means something that converts into a palatable 
pabulum, and assumed that they played an important 
part in the establishment of immunity. He also de- 
monstrated that their amount was decreased in certain 
pathological conditions, and increased by inoculating the 
individual with dead bacteria of his disease. He thought 
that by this method the cure of certain diseases could be 
effected. He introduced the following method of meas- 
uring the quantity of opsonins : The serum of the 
patient is mixed with equal portions of an emulsion of 

i Proc. Royal Sec, 1903, lxxii., 357, and 1904, lxxiii., 128. 
2Deutsch Med. Woch., 1904, xxx., 1358, 



CLASSIFICATION. 61 

bacteria and a suspension of leucocytes obtained by centri- 
fugating citrated blood, and removing with a pipette the 
upper layers of corpuscles which contain the leucocytes. 
This mixture is incubated for fifteen minutes at a temper- 
ature of 37 °C, and then spread on slides. A similar 
control smear is made from normal serum. The average 
number of bacteria in each leucocyte is determined by 
counting the number in fifty leucocytes on each slide. 
The patient's opsonic index is the quotient obtained by 
dividing the average number of the smear of the patient's 
slide by the average number of the control slide. Other 
workers have tried to improve and simplify Wright's 
technic. It is generally conceded that the determination 
of the opsonic index is fraught with so many difficulties, 
and liable to so many errors that it is not yet on a relia- 
ble basis. While the best results are thought to be 
obtained by using opsonins made from the blood of the 
patient, stock cultures are now used by some experiment- 
ers. The dose varies from 300 to 2,500 million cocci. 
It is advised to begin with a small dose, and increase or 
diminish it according to the effect produced on the pha- 
gocytosis. Good results have been reported in pyogenic 
diseases of the skin, such as furuncles, acne, and sycosis ; 
and in tuberculosis. The whole matter is in an experi- 
mental state, and, as the method requires the use ot 
laboratory facilities, and is complicated, it is not of prac- 
tical use to the average physician. 

Classification. 

In the present state of our knowledge it is impossible 
to make a satisfactory classification of skin diseases. 
Many attempts have been made to do this, and are still 
being made. Hebra's classification modified is found in 
a great many text-books. The arrangement of this book 
does away with classification. The one here given fol- 
lows that given by Crocker, and has proved itself, after 
a number of years of use, a practical one. 



62 



GENERAL CONSIDERATIONS. 



CLASSIFICATION AND NOMENCLATURE. 



Class I. HYPEREMLE. 

II. EXUDATIONES. 

III. HEMORRHAGIC.' 

IV. HYPERTROPHIC 
V. ANOMALIES OF PIGMENTATION. 

VI. ATROPHIC 

VII. NEUROSES. 

VIII. NEOPLASMATA. 

IX. MORBI APPENDICIUM. 

X. PARASITI. 



Class I. HYPEREMIA— CONGESTIONS. 



Erythema simplex. 
" pernio. 
" intertrigo. 
" scarlatiniforme. 
" fugax. 
" roseola. 



Most prominent primary lesion. 
Erythema. 



Class II. EXUDATIONES— INFLAMMATIONS. 



Erythema exudativum multiforme 
Poliosis rheumatica. 
Erythema nodosum. 

" " elevatum di- 

utinum. 
Pellagra. 
Acrodynia. 
Urticaria. 

" pigmentosa. 
Eczema. 
Dermatitis repens. 

Impetigo contagiosa. 

Folliculitis. 

Pompholyx. 

Herpes. 

" progenitalis. 

Zoster. 

Pemphigus. 

" neonatorum. 

Epidermolysis bullosa. 

Equinia. 

Hydroa, seu Dermatitis herpeti- 
formis. 

Impetigo herpetiformis. 

Dermatitis. 

" epidemica. 

Psoriasis. 

Pityriasis rubra, seu Dermatitis ex- 
foliativa. 



Most prominent primary lesion. 
. Erythema and papules. 

Erythema in soft swellings. 



Erythema. 

Wheals. 

Persistent wheals. 

Multiform lesions. 

Epidermic denudation and fluid 

exudation. 
Vesicles and pustules. 
Hair-follicle pustules. 
Bullae and vesicles. 
Grouped vesicles. 

Grouped vesicles. 

Bullae. 
a 

Bullae. 

Multiple lesions. 

Grouped multiform lesions. 

Grouped pustules. 

Multiform lesions. 

Erythema and papules. 

Scaly crusts on red base. 

Diffuse redness with large scales. 



CLASSIFICATION AND NOMENCLATURE. 



63 



Pityriasis rosea^ 

Lichen scrofulosorum. 
" pilaris. 
" planus. 
" ruber. 
" variegatus. 

Pityriasis rubra pilaris. 
Prurigo. 
Furunculus. 
Carbunculus. 
Abscess. 

Pustula maligna. 
Ulcus. 
Erysipelas. 

Conglomerative pustular folliculi- 
tis. 
Dermatitis gangrenosa. 



Oval, scaly, red patches, with yel- 
lowish centre. 
Papules, grouped. 

" follicular. 

" flat, angular. 

" acuminate, scaly. 

" flat,and reticulated scaly 
spots. 

" acuminate, scaly. 

" lenticular. 
Phlegmonous. 



Loss of substance. 

Erythema with brawny swelling. 

Patches of aggregated pustules. 



Gangrene. 



Class III. HEMORRHAGIC— HEMORRHAGES. 



Purpura. 
Scorbutus. 



Blood extravasation. 



Class IV. HYPERTROPHIC— HYPERTROPHIES. 



Ichthyosis. 

Keratosis pilaris. 

Acanthosis nigricans. 

Verruca. 

Clavus. 

Cornu cutaneum. 

Callositas. 

Tylosis. 

Porokeratosis. 

Angiokeratoma. 

Keratosis follicularis. 

" pilaris. 

Scleroderma. 
Morphoea. 

Sclerema neonatorum. 
CEdema " 

Elephantiasis. 
Acromegaly. 



Parts affected. 
Epidermis and papillae. 
Papules about hair follicles. 
Epidermis and papillae. 



Epidermis. 

Sweat-orifice keratosis. 
Follicles. 



Hair follicles. 
Corium. 



Whole skin. 



Class V. ANOMALIES OF PIGMENTATION. 



Chloasma. 

Lentigo. 

Albinism. 

Leucoderma. 

Melanoderma. 



Pigment. 



64 



GENERAL CONSIDERATIONS. 



Class VI. ATROPHLE— ATROPHIES. 



Atrophia cutis propria. 
Atrophoderma senilis. 

" striatum et macu- 

latum. 
Atrophoderma pigmentosum. 
Ainhum. 



Parts affected. 
Corium. 



Class VII. NEUROSES-SENSORY DISEASES. 



Hyperesthesia. 
Dermatalgia. 
Pruritus. 
Anesthesia. 
Ulcus perforans. 
Morvan's disease. 



Class VIII. NEOPLASMATA— NEW GROWTHS c 



> Degeneration. 



1- Infiltrating. 



Infiltrating. 



Molluscum 

Colloid degeneration 

Xanthoma > 

Lupus vulgaris 1 

" erythematosus 
Scrofuloderma 
Tuberculosis 

" verrucosa cutis 

Erythema induratum 
Syphiloderma 

Lepra ] 

Rhinoscleroma 

Leucoplakia J 

Keloid 
Fibroma 
Acrochordon 
Myoma 
Neuroma 
Nevus vasculosus 

" pigmentosus [-Benign 

Telangiectasis 
Angioma serpiginosum 
Angiokeratoma 
Rosacea 
Lymphangioma 
Dermatolysis 
Carcinoma 
Paget's disease 
Epithelioma 
Sarcoma 
Sarcoid 
Leukemia and pseudoleukemia 

cutis \ Malignant. 

Mycosis fungo'ides 
Yaws 

Verruga Peruana 
Furunculus orientalis 
Phagedena tropica 
Acanthoma 



CLASSIFICATION AND NOMENCLATURE. 



65 



Class IX. 



MORBI APPENDICUM— DISEASES OF THE 
APPENDAGES. 



A. Sweat Glands. 
Hyperidrosis. 
Bromidrosis 
Chromidrosis 
Haeinatidrosis 
Uridrosis 
Anidrosis. 

Miliaria crystallina (sudamina) 

" papulosa. 
Hydrocystoma. 

B. Sebaceous Glands. 
Seborrho3a. 

Seborrhoeic dermatitis. 
Milium. 

Comedones. 
Acne vulgaris. 

" rosacea. 

" varioliformis. 

" agminata aud folliclis. 

Sebaceous cyst. 
Adenoma sebaceum. 
Asteatosis. 

C. Hair. 
Hyp ertrichosis. 
Atrophia. 
Alopecia. 

" areata. 
Concretions. 
Trichorrhexis nodosa. 
Canities. 
Sycosis. 

Folliculitis decalvans. 
Dermatitis papillaris capillitii. 
Naevus pilosus. 

Plica Polonica. 

Trichiasis. 

Distichiasis. 

D. Nails. 
Pterygium. 
Onychia. 
Paronychia. 
Atrophia. 

Ony c hogryphosis. 
Onychomycosis. 
Leucopathia unguium. 



Most prominent primary lesion. 
Excessive secretion. 

Altered quality. 



Deficient secretion. 
Vesicles. 
Inflammation. 
Vesicles. 



Excessive secretion. 

Multiple inflammatory lesions. 

Retained secretion. 

Inflammation. 

Redness and pustules. 

Inflammation. 

Aggregated and disseminated 

pustules. 
Retained secretion. 
Papules. 
Deficient secretion. 

Excessive growth. 
Defective growth. 
Baldness. 

" in patches. 
Growths on the hair shaft. 
Nodes on hair shaft. 
Loss of pigment. 
Inflammation. 

Alopecia with inflammation. 
Inflammation. 
Excessive growth with pigmenta- 

tion. 
Felting. 
Misplacement of cilia. 



Overlapping of nail fold. 

Inflammation. 
a 

Defective growth. 
Overgrowth. 
Fungus growth in nail. 
White spots in nails. 



Class X. PARASITI— PARASITES. 



A. Vegetable. 
Favus. 

Trichophytosis. 
Tinea imbricata. 



Parasite- 



-Aehorion. 
Trichophyton. 



66 



GENERAL CONSIDERATIONS. 



A. Vegetable. 

Chromophytosis ( tinea versicolor ) . Parasite 
Erythrasma. " 

mum. 
Mycetoma. Tumors. 

Actinomycosis. " 

Pinta. Discolored macules. 

Blastomycosis. Tumors. 

B. Animal. 

Scabies. 

Demodex folliculorum* 

Leptus autumnalis. 

Pulex penetrans. 

Estrus. 

Larva migrans. 

Pediculosis. 

Cysticercus cellulosae cutis. 

Dracontiasis. 



-Mierosporon. 
Mierosporon minutissi- 



Parasite — Acarus. 



Parasite- 



-Pediculus. 
-Taenia solium. 
-Filaria medinensis. 



PAET II. 

THE DISEASES OF THE SKIN AND THEIR 
TREATMENT. 



Abscess. 

Symptoms. Abscesses are very frequently met with 
as complications of diseases of the skin, such as acne, 
eczema, scabies, pediculosis, and other acute dermatitides. 
As thus met with they are usually of small size, though 
at times, as upon the scalp of a strumous child, they may 
attain considerable dimensions. They form rounded 
swellings that are at first tense but soon become soft and 
fluctuating. When incised, more or less thick pus 
escapes. Their most frequent locations are : upon the 
scalp with eczema ; upon the face and back with acne ; 
about the neck arising from broken-down glands ; and 
upon the extremities with scabies and pediculosis. Apart 
from a slight amount of discomfort, they do not give 
rise to subjective symptoms as a rule, and are, indeed, 
trivial affections. Of course this does not apply to 
abscesses as seen by the surgeon. They may open of 
themselves and discharge their contents upon the skin. 
More commonly they are very sluggish in their 00111*86, 
and must be evacuated by some surgical procedure. 
Cutaneous abscesses are most commonly due to micro- 
organisms. 

Diagnosis. An abscess differs from a furuncle by 
not being raised into a conical mass ; not having a central 
core, and by being less firm to the touch. It differs from 
a carbuncle by an entire absence of marked constitutional 
disturbance, brawny infiltration, intense inflammation, and 
cribriform mode of opening. Kerion often resembles an 
abscess, but differs from it in its uneven surface and its 

67 



68 DISEASES OF THE SKIN. 

firmness to the touch. Syphilitic gummata are sometimes 
mistaken for abscesses and opened. They may be recog- 
nized by their dark-red color, the absence of pain and 
discomfort, and the history of their growth. They grow 
slowly, beginning below the skin. There is generally 
more than one present, and then they are grouped. The 
aspiration of the tumor will decide the question. From 
an abscess we obtain pus ; from a gumma a little bloody 
fluid. 

Treatment. The management of the small cutaneous 
abscesses that we meet with as dermatologists is simple. 
The cavity is to be opened, the pus allowed to escape, 
and the part dressed with carbolized vaseline if small, or 
antiseptically if larger. It is sometimes necessary to 
swab out the cavity with a solution of carbolic acid of 
two drachms to the ounce, to destroy the abscess wall 
and prevent the reformation of the abscess. 

Acantholysis. A disease characterized by loosening or 
separation of the mucous layer of the epidermis. See 
Epidermolysis. 

Acanthosis Nigricans. Under this name cases have 
been reported by Pollitzer, Janovsky, Crocker, and a 
few others. It occurs at any time of life, but most often 
between the thirtieth and fortieth year. The first symp- 
tom may be pigmentation of the face and neck ; or an 
eruption of warts on the backs of the hands or thighs ; 
or itching on the inside of the thighs or in the mouth. 
It consists in a dirty-brown to bluish-gray or black 
discoloration of the skin and mucous membranes, with 
more or less papillary outgrowths and seborrhceal warts. 
On the places that are most discolored the papillary out- 
growths are most marked. The skin is thickened to a 
greater or less degree, and is not scaly. The eruption is 
more or less general, but the regions most often affected 
are the face, neck, mucous membranes of the mouth 
(especially the tongue), the backs of the hands (especially 
the fingers), the axilla?, groins, genito-anal regions, and 



ACNE. 69 

abdomen. Women are more often affected than men. 
Most cases occur after the forty-sixth year. It may occur 
as early as the second year. Late in the disease the hair 
and nails are lost. The cause of the disease is unknown. 
Bille 1 regards it as a form of keratosis. Darier, J. 
Burmeister, 2 and others say that it is often due to cancer 
affecting the abdominal sympathetic. The prognosis is 
bad, death resulting in from eight months to two years. 
In some cases the duration is much longer. A cancerous 
cachexia is often developed and cancerous degeneration 
of some abdominal organ recognized. Treatment thus 
far has been unavailing. 

Acne. Synonyms : Varus, Ion thus ; (Ger.) Finnen ; 
(Fr.) Acne, Bouton ; Stone-pock, Whelk, Pimple. 

Acne is an inflammatory disease of the sebaceous 
glands and the hair follicles, characterized by an eruption 
of papules, pustules, or tubercles upon the face, neck, 
shoulders, or chest, which usually begins at puberty and 
tends to run a chronic course. 

There are two varieties of acne, namely, acne vulgaris 
and acne indurata. 

Acne Vulgaris, or Simplex, is either papular or pustular 
in character, though usually it is a combination of the 
two, together with more or less comedones and a certain 
amount of seborrhoea. 

Symptoms. If only papules exist (A. papulosa), the 
face, shoulders, or chest will be found to be dotted more 
or less profusely with pinhead-sized, acuminated eleva- 
tions of the skin, of a pinkish to red color, and with a 
central opening at the summit. Very often the central 
openings will be filled with blackish specks. The lesions 
are then spoken of as A. punctata. There are many 
comedones present. It is rare that acne exists only in 
the papular form. More usually it will be found that 
here and there the papules are surmounted by a pustule, 

1 Wien. med. Wochenschr., 1897, xlvii., 1019. 

2 Arch, f. Dermat. u. Syph., 1899, xlvii., 343. 



70 



DISEASES OF THE SKIN. 



or a pustule has takeu the place of a papule. We now 
have A. pustulosa. The central black point is wanting. 
In strumous subjects the pustular element preponderates 
over the papular, and the face may be greatly disfigured 
by the large number of lesions present upon it. The 
pustules are from pinhead to small-pea size and have an 
inflamed base. (Fig. 7.) 

The lesions of acne are located on the face, the tops 
of the shoulders and on the chest and back. True acne 

Fig. 7. 




Acne vulgaris. 
(By the courtesy of Dr. S. I. Rainforth.) 

rarely is found below the free border of the ribs anteriorly 
or posteriorly. 

Together with the acne and the comedones we meet 
with milia quite commonly, and the affected parts are 
usually greasy to the feel, showing that the sebaceous 
glands sympathize in the disease. We now have a fair 
picture of a typical case of acne vulgaris. The face, 
back, neck, chest, and shoulders, or all five, are dotted 
over in an irregular manner with blackish points, 
papules, and small pustules ; the skin of the nose and 
forehead looks shiny and feels greasy, aud perhaps there 



ACNE. 71 

are some milia scattered about the region of the eyes. 
At times the eyes will appear inflamed and hypersemic, 
especially in young, otherwise robust subjects. More 
commonly the complexion will have that pasty appear- 
ance indicative of what has from old times been called 
the strumous condition. Not unfrequently the skin is 
abnormally red. If the inflammatory process has been 
unusually severe, we may find a considerable amount of 
scarring. Usually acne vulgaris does not leave perma- 
' nent scars. The profuseness of the eruption varies greatly. 
In some cases there will be but a few lesions, while in 
other cases they will be present in vast numbers. This 
form of acne generally occurs in young people. The 
duration of the individual lesion is short, as it soon either 
dries up or discharges its contents. If the papules are 
squeezed, vermicelli like masses of sebaceous matter will 
be expressed. If the papulo-pustules are treated in the 
same way, there will first be pressed out a drop or two 
of pus, and then more or less of a sebaceous plug. 

Acne Indurata is a pustular acne in which the pustules 
are of large size and seated upon deeply infiltrated bases. 
They are most commonly sparsely dispersed, and take 
the form of purplish " lumps " of pea to bean size which 
are hard to the touch. Sometimes they are more readily 
appreciated by touch thau by sight, being located deeply 
in the skin. Sometimes they take the form of cutaneous 
abscesses, and if by chance several are located close to 
one another they may run together and form a raised, 
dark-red, doughy mass. When incised, these lesions 
sometimes give exit to a large amount of thick pus. 
They usually leave scars, which sometimes are very dis- 
figuring unless they are opened very early in their course. 
It may be the only form of acne present, or it may be 
combined with acne vulgaris. This form of acne usually 
occurs at a more advanced age than does acne vulgaris, 
though it is not infrequently met with in early life, and 
may persist throughout life. While occurring on the 



72 DISEASES OF THE SKIN. 

face, the neck and back are the regions in which it is 
prone to develop in the most marked manner, and to be 
most persistent. (Fig. 8.) 

Etiology. Acne is one of the most common of skin 
diseases, and its great predisposing cause is youth. The 
disease first shows itself about the time of puberty and 

Fig. 8. 



Acne indurata of the back. 

manifests a tendency to disappear when the body is fully 
developed — that is, from the twenty -third to the thirtieth 
year, although it may continue much later. A few rare 
cases have been reported of acne at an early age. Thus, 
Chambard 1 met with a case in a girl aged six and a half 
years. The indurated form of acne appears later than 
the simple form, usually after the twenty-fifth year. 
Both sexes are affected, but the disease is more frequent 

i Ann. de derm, et de syph., 1878-79, x., 259. 



ACNE. 73 

in females than in males, and in them begins at an earlier 
age. The period of youth is the time of great develop- 
mental activity in which the sebaceous glands take part, 
and it is at this time we frequently have a seborrhoea of 
the face and other parts. In nearly every case of acue 
the skin of the nose is greasy and feels slippery to the 
touch. This greasy skin is another predisposing cause 
of acne. It provides a favorable soil for the growth of 
the bacillus acnes, which probably is the exciting cause of 
the disease. 

Individuals with thick, pasty, pale skins, with patu- 
lous follicular mouths are predisposed to acne. These 
peculiarities of skin are met with in scrofulous subjects. 
The patulous follicular mouths give ready lodgement to 
foreign matters, and comedones are thus, formed. This 
prevents the escape of the follicular contents, a plug is 
formed, and we have an acne papule or pustule. Come- 
dones are, therefore, an exciting cause of acne. 

Heredity has been asserted by some to be a predispos- 
ing cause of acne, but the disease is so common that there 
is no certainty about this factor. 

Digestive disturbances, while not causing acne, are 
most active in aggravating it, as they increase the con- 
gestion of the skin and the seborrhoeal condition. These 
may take the form of dyspepsia, stomachal or intestinal ; 
or malassimilation ; or failure on the part of the liver or 
pancreas to perform its physiological functions ; or slug- 
gishness of the large intestine and consequent constipa- 
tion. Improper diet, so common in early life, is respon- 
sible for the- maintenance of many cases of acne. 

Next" to disorders of the digestive organs, those of the 
sexual organs are supposed to have most influence in 
aggravating acne. But, inasmuch as most cases of acne 
are amenable to the influence of diet and regulation of 
digestive disorders without any attention being given to 
sexual disorders, it is probable that the latter are im- 
portant etiological factors in comparatively few cases. 
Indeed, it is not improbable that the acne that appears 



74 DISEASES OF THE SKIN. 

on the faces of women at each menstrual period, and at 
that time alone as well as the aggravation of an already 
existing acne, is due to the more or less pronounced 
disturbance of the digestive organs so frequently observed 
at the same time. In some cases acne does seem to be a 
reflex irritation from the uterus, Amenorrhoea is the 
uterine derangement most frequently encountered, but 
that condition is but one evidence of a general constitu- 
tional disorder rather than a disease in itself. 

Masturbation and continence have each been blamed 
as excitants of acne. The former of these of itself does 
not cause acne, but its well-known effects on the nervous, 
moral, and physical condition of growing youths would 
sufficiently account for any part it may have in produc- 
ing acne. There is absolutely no proof that continence 
causes acne. It is safer to say that bad sexual hy- 
giene may cause acne, rather than to ascribe it either to 
masturbation on the one hand or to continence on the 
other. 

It may be stated as a broad, general rule, that anything 
that lowers the general health of the patient contributes 
to the production of acne. We have space to enumerate 
only some of these exciting causes. Thus, we have the 
vague state " general debility/' anaemia and chlorosis, 
oxaluria and uraemia, rheumatism and gout, poor circu- 
lation, mental and physical exhaustion, and chronic 
malaria. J. Schutz x believes that deficient heart action 
and consequent slowness of the circulation are the under- 
lying causes of acne, as they lead to an alteration of the 
sebaceous secretion. 

Pathology. Acne may begin in the hair follicles or 
in the sebaceous glands, and may be due either to their 
becoming clogged up by inspissated sebum and acting 
like a thorn in the flesh, or to their invasion by micro- 
organisms, either from without or within, which set up a 
suppurative perifolliculitis. The papules of acne are 

i Arch. f. Dermat. u. Syph., 1900, li., 323. 



ACNE. 75 

located in the upper part of the skin, while the pustules 
are deeper. In very bad cases the follicle may be 
entirely destroyed by the perifolliculitis and scars will be 
left. The sebaceous glands do not take a very active 
part in the process. Microorganisms are found abun- 
dantly in the suppurating gland cavities. 

In acne indurata Ave find the hair follicles enormously 
dilated, their orifices filled with corneous cells, and their 
cavities almost converted into cysts. The connective 
tissue about the follicles shows decided signs of inflamma- 
tion and may be increased in amount. Very often the 
follicles are destroyed by the perifollicular inflammation. 
When the perifolliculitis is severe and extensive the deep 
layers of the skin become involved, and we have abscess 
formation. 

According to Unna the comedo is not due to stopping 
up of the follicle by extraneous matter, but to a hyper- 
keratosis closing up the follicle mouth, and the black head 
is due to degeneration of the compressed horny cells. 
Unna, Sabouraud, and Gilchrist each describe a special 
organism as the cause of acue. Unna found a flask bacil- 
lus and a diplococcus, and another bacillus. Sabouraud 
describes still another bacillus as the cause of the disease, 
and believes that the invasion of the infected follicles by 
staphylococci of gray culture produces the pustular form. 
Gilchrist's baccillus acnes is pyogenic. It is short and 
thick, straight or curved, and sometimes branched. Both 
Sabouraud and Gilchrist teach that the seborrheic skin 
is the proper ground for infection by their microorgan- 
isms. It seems evident, therefore, that the disease is 
parasitic, and this theory best explains the course of the 
disease. As one grows older the character of the skin 
changes, so that it is no longer a proper habitat for the 
organisms, just as in ringworm of the scalp, which 
undergoes spontaneous recovery after puberty is reached. 
In all pustular lesions the common forms of staphylococci 
are found. 

Diagnosis. Acne is to be differentiated from rosacea, 



76 DISEASES OF THE SKIN. 

papular and pustular eczema, sycosis, the small pustular 
and tubercular syphiloderm, and variola. 

Rosacea is due to a dilatation of the bloodvessels, and 
is attended by hyperemia and telangiectases. If there 
are any pustules, they are superficial, and if excised give 
exit to only a drop of pus. Acne is a disease of the 
sebaceous glands, and papules and pustules constitute the 
disease. They are often large, and if excised will give 
exit to a plug of sebaceous matter and thick pus. 
Rosacea, as a rule, occupies the middle third of the face 
alone, the forehead, nose, and chin. Acne is scattered 
over the whole face, and is often found on the shoulders. 

Papular eczema may occur at any age ; acne usually 
occurs between the ages of fifteen and twenty-five. 
Papular eczema rarely is seen on the face alone, and is 
prone to attack the trunk and extremities ; acne often 
occurs on the face alone, and is never disseminated over 
the limbs and trunk. In eczema there is an absence 
of comedones ; the papules are often surmounted by or 
change into vesicles ; they tend to form patches, and the 
disease is very itchy, so that scratch-marks are almost 
invariably found. When it gets well it leaves no trace 
on the skin. These symptoms are foreign to acne. 

In pustular eczema, or what has been called impetigo 
simplex, we have a large number of small pustules run- 
ning together to form patches which rapidly become 
covered with greenish or yellow crusts. The disease 
runs a far more acute and stormy course than does acne, 
and is itchy. It is very frequently met with in children, 
whom acne rarely affects. 

Sycosis is a pustular disease affecting the hair follicles 
alone, each pustule being pierced by a hair. Acne occurs 
on the non-hairy as well as the hairy parts, and, indeed, 
shows preference for regions supplied only with rudi- 
mentary hairs. 

Acne necrotica is specially located along the hair-line, 
and invades the scalp, which acne never does. It also 
runs a more sluggish course and leaves variola-like scars. 



ACNE. 77 

The small pustular syphiloderm, or syphilitic acne, is a 
general eruption, and it is easy in most cases to obtain 
other evidences of syphilis, such as the remains of the 
initial lesion, enlarged lymphatic glands, mucous patches, 
or the like. It is usually more uniform in its lesions, 
and these are plainly papulo-pustular. The color of the 
areola is more that of raw ham and less inflammatory 
looking than is that of acne. The lesions sometimes 
show a tendency to group into segments of circles, and 
each lesion undergoes a definite development. They 
sometimes leave small, smooth, white scars that may 
disappear in a few months. They are not confined to 
the chest alone but are scattered over the body. The 
tubercular syphiloderm could be mistaken for an indurated 
acne. In it there will usually be found other evidences 
of syphilis. The lesions group themselves into patches 
that are kidney-shaped or form segments of circles. 
The tubercles are dark-red or raw-ham colored, sur- 
rounded by a well-marked areola, firm to the touch, and 
do not contain pus. They may ulcerate, or, being 
absorbed, leave pigmented and punched-out cicatrices, 
and, finally, smooth white scars. The scars left by acne 
indurata are puckered and more disfiguring. 

Variola could scarcely give rise to much doubt, as it 
has well-marked constitutional symptoms, and its lesions 
undergo a definite and characteristic development. 

Treatment. In the treatment of acne we can obtain 
a cure most rapidly by a combination of internal and local 
treatment. 

We, therefore, begin the treatment of a case by a careful 
inquiry into the general condition of the patient, and 
endeavor to regulate any, even the slightest, derangement 
of the internal organs. By so doing we may find no one 
of those conditions enumerated under the etiology of the 
affection, and the patient may consider himself as in the 
best condition. Further observation will probably reveal 
some deviation, though slight, from perfect health. The 
relief of constitutional disorders is conducted according to 



78 DISEASES OF THE SKIN. 

the principles of general medicine, and cannot be given 
here. Many of the cases require cod-liver oil and iron as 
general measures quite apart from any evident disease. 
This is seen in the sluggish cases occurring in strumous 
subjects with pasty skins. In plethoric subjects with a 
good deal of inflammation attending the acne, laxative 
agents, such as a T \ of a grain of calomel in tablet tritu- 
rates, given three or four times a day, will aid in a cure, 
quite aside from overcoming any constipation. Whit- 
field recommends menthol in 1 to 2 grain doses after 
each meal to subdue gastric reflexes and flushing of the 
face. 

Diet and hygiene are to be employed rather than 
drugs. It is impossible here to lay down fixed principles 
of diet, and it is better to study each case by itself. A 
good rule is to cut off all sweets, pastry, and cake, and 
give for breakfast and luncheon, or supper, a cereal, but 
not oat meal, with milk and cream, bread and butter, 
and fruit. For dinner meat, vegetables, salads with 
plain dressing, and light puddings may be allowed. A 
cup of coffee may be permitted in the morning, but no 
tea or alcoholics. The food must be well masticated. 
It must be remembered that milk is a food, and that 
when other foods are partaken of freely the taking of 
milk at the same time may overload the stomach. The 
omission of milk from the dietary will be of great benefit 
in some cases of acne. Hot water before meals, a glass 
of water at meals, two hours after meals, and on going to 
bed, are good directions for the use of beverages. Butter 
may be used freely, and care must be had not to re- 
strict the diet too greatly. Many young girls almost 
starve themselves in the mistaken idea that a low diet 
will give them a fine complexion. 

Exercise must be insisted on, an hour or more a day 
being spent in walking, horseback or bicycle riding, row- 
ing, or other out-door exercise. Daily bathing or dry 
rubbing will keep the skin in healthy condition, and 
Turkish baths are often beneficial. Where a shower 



ACNE. 79 

bath is at hand it is well to have the patient stand in 
about four inches of warm water, and allow the shower to 
fall first warm and then cold ; this to be followed by 
brisk rubbing with a coarse bath towel. Where patients 
either cannot or will not take a daily bath, much good 
will be accomplished by having them bathe the chest and 
back daily with cold water and then dry the skin by 
brisk rubbing with a coarse towel. 

Arsenic, sulphide of calcium, glycerin, and ergot are the 
drugs that are given by the mouth as curative in acne. 
Arsenic is the oldest and most honored of these. It is of 
use only in very chronic, sluggish cases, and the more 
papular the case the more useful the arsenic. It should be 
used as the last resort, not as the first. Fowler's solution 
is the most frequently used preparation, in doses of from 3 
drops three times a day, as an initial dose, gradually in- 
creased to 15 or 20 drops or until the appearance of some 
symptoms of poisoning. Piffard 1 recommends bromide of 
arsenic in the dose of T h to fa grain two or three times 
a day in rather acute cases of acne. A convenient method 
of administration is to make a 2 per cent, solution in alco- 
hol, and give 1 or 2 minims of that in a wineglassful of 
Avater. Should it cause gastric irritation the dose must be 
lessened. I have used this in a number of cases with good 
results. The sulphide of calcium has its advocates for 
sluggish pustular cases. It should be given in small 
doses, from T Jo to T V grain, in gelatin-coated pills or fresh 
tablet triturates. One pill may be given four or five 
times a day until the tendency to pustulation is increased. 
It then should be discontinued until the exacerbation has 
subsided, when it should be again administered. It is 
of doubtful value. Glycerin was advocated by Gubler 2 
as a cure for acne, and is well spoken of by others. It 
must be given in doses of a teaspoonful three times a 
day, increased to a tablespoonful, and is of most use in 

1 Joum. Cutan. and Ven. Dis., 1884, ii., 71. 

2 Jo urn. de Bruxelles, 1870. 



80 DISEASES OF THE SKIN. 

strumous cases. Ergot, either the fluid extract iu doses 
of J a drachm three times a day or a corresponding 
amount of ergotin, has many advocates. 

Chrysarobin, internally, has been recommended by 
Stocquart, 1 in the dose of \ to J grain. Small doses 
of the bichloride of mercury are sometimes .curative 
where there is much infiltration. 

Iodide of potassium in doses of from 1 to 5 drops 
of a saturated solution, well diluted, taken three times a 
day before meals, sometimes is useful in pustular acne. 

As acne is a local infection of the skin I have little 
faith in the administration of drugs for its cure, except to 
meet symptoms. But A. C. Wright 2 has found that 
inoculations with a staphylococcic vaccine, cultures of 
staphylococci sterilized by heat, have given excellent 
results. His theory is that the patient's blood is thus 
made immune to the infection. 

Sherwell 3 advocates the passage of the cold sound 
through the urethra of a young man suffering with acne. 
Hot vaginal douches are recommended by some in acne 
of women. 

The objects of local treatment are to open up the pus- 
tules and papules and allow of the escape of their con- 
tents, to stimulate the skin to a more healthful action, 
and, according to the bacteriologists, to prevent further 
infection of the follicles by microorganisms. To attain 
the first two objects we may employ either a quick or a 
slow method ; to attain the last object we employ an anti- 
parasitic. The best preventive local treatment is to keep 
the skin clean and its nutrition good by the use of soap 
and water. I have found benefit from the use of a soap 
made from the waters of Kreuznach Springs, with the 
addition of sulphur, and known as Kreuznach Soap, No. 
2. It is to be used as an ordinary soap at first; later 
the lather is to be left on for a few hours; and still later 

1 Ann. de derm, et de syph., 1884, v., 15. 

2 Brit. Med. Journ., 1904, 1., 1075. 

3 Journ. Cutan. and Ven. Dis., 1884, ii., 335. 



ACNE. 



81 



all night. It smarts for a few minutes at first, and 
causes some skins to exfoliate. 

An efficient local treatment for nearly all cases of acne 
is to put the skin on the stretch and scrape it somewhat 
roughly with a large and long, blunt dermal curette with 
a fenestrated blade (Fig. 9). This tears off the tops of 
all the lesions, presses out all the contents of the follicles, 
and stimulates the skin in a most vigorous manner. It 
is followed by some bleeding, which it is well to encour- 




Fox's ring curette. 

age by the use of warm water. Deep pustules or cuta- 
neous abscesses, if not emptied by the curetting, should 
be incised. All comedones should be squeezed out. The 
after-treatment consists in washing the face with warm 
water and soap and dusting with cornstarch, to which 
may be added oxide of zinc. Instead of this a solution 
of peroxide of hydrogen or of bichloride of merc^fcl in 
1,000 may be dabbed on. The scraping is to be^Hated 
two or three times a week. The procedure seems rough, 

Fig. 10. 



Fox's acne lance and dermal curette. 



but after the first scraping the patients do not mind it 
much, and the result is the attainment of a smooth skin 
in a comparatively short time. With this plan we may 
use a sulphur ointment, a drachm to the ounce, to be 
applied twenty-four hours after the scraping, or a lotion 
of bichloride of mercury, or peroxide of hydrogen. Thus 
we will fulfil all three of the indications for treatment. 

The same results can be attained in a slower way by 
opening every pustule with an acne lancet (Fig. 10) and 
6 



82 DISEASES OF THE SKIN. 

squeezing out every comedo. This is to be done once or 
twice a week and a sulphur preparation used between 
times. Very timid patients who will allow no surgical 
interference may be treated according to the same prin- 
ciples by directing them to scrub their faces thoroughly 
once a day with green soap, or tincture of green soap, and 
leave the lather on. After a day or two of good scrub- 
bing sufficient dermatitis will be excited to cause the old 
skin to peel off, while the tops of many of the lesions 
will have been torn off and the skin will have been 
decidedly stimulated. Not until the skin has become 
scaly and feels tense to the patient should a soothing 
ointment be applied. Repeated applications of the soap 
frictions will slowly bring about improvement. Instead 
of the green soap, Kreuznach Soap, No. 2, may be used. 
Rubbing the face with fine sand or coarse cornmeal will 
do good, but is not so elegant. 

Massage to the skin will give nearly if not quite as 
good results as the rougher curettage. The tips of the 
fingers should be dipped in cold cream, and then, pressure 
beiujgfccerted by them, the skin of the forehead should be 
deeMKtroked from the middle line out and over the 
temj^^ The nose should be stroked from the bridge out- 
ward and downward. The skin of the cheeks should be 
pinched up and rolled between the fingers and thumb. 
These movements facilitate the emptying of the follicles. 
Stel wagon makes the good suggestion that instead of man- 
ual massage a small cupping glass with one inch opening 
should be used. Sometimes massage spreads the disease 
and must be stopped. The application of the galvanic 
current by means of the roller electrode, or by ordinary 
sponge electrodes, will in some sluggish cases prove help- 
ful. G. W. Wende 1 recommends placing the electrodes 
in close proximity on the face and constantly changing 
their position until the skin becomes reddened. The 
amount of current to be used depends upon the ability of 

i Buffalo Med. Journ., 1898-99, xxxviii., 254. 



ACNE. 83 

the patient to bear pain. Where the skin is very sensi- 
tive the anode can be held in one place and the face 
gently stroked with the cathode, using 5 to 10 cells 
for fifteen minutes. Stel wagon speaks well of the fa radio 
current where there is sluggish muscular tone, using it 
strong enough to produce slight muscular reaction. 

A vast number of prescriptions have been written 
which are "good for acne/' the majority of which con- 
tain sulphur in some form, and in the strength of J a 
drachm to 1 drachm to the ounce, and in ointment or 
lotion form. Sulphur in powder form is good if the 
patient does not mind the odor. The ordinary sulphur 
ointment of the Pharmacopoeia is as good a preparation 
as any. It may be made more elegant by adding some 
perfume, and more efficient by adding 2 per cent, of sali- 
cylic acid. The sulphuret of potassium may be used in 
the following: 



R Potass, sulphuret., i -- „• g- 3 | 5 

Zinci sulphat. , J 

Aquae rosse, ad ^iv; 100| 



M. 



This preparation is commonly spoken of as " Lqfl B^a," 
and is one of the most useful of the compound^ ^Fsul- 
phur. It is to be applied every day after being Well 
shaken. It is often rendered more active by adding to 
it a drachm of precipitated sulphur. 

Mercurial preparations may be used to more advantage 
in some cases than those of sulphur. It should be borne 
in mind that a mercurial must never be applied to the skin 
until all traces of sulphur are removed, or vice versa, be- 
cause if the precaution is forgotten the black sulphide of 
mercury will be formed, which will give the skin the 
appearance of being sown with powder grains. A lotion 
of corrosive sublimate, 1 to 2000 to 1 to 1000, may be 
mopped on once or twice a day, or an ointment of the 
protiodide, as recommended by Duhring, may be used : 

R 

Hydrarg. ammon., gr. x-xxx; 2 

M. 



Hydrarg. protiodid., 


gr. v-xv ; 


1 


Hydrarg. ammon,, 


gr. x-xxx ; 


2 


Ungt. simplicis, 


&'; 


30 



84 DISEASES OF THE SKIN. 

Lassar 1 recommends the following paste 
R 



/3-naphtol, 


10 parts. 


Sulph. praecip., 


50 " 


Vaseline, \ 
Sapo viridis, ' 


aa 25 " 





M. 

This is to be spread upon the skin to the thickness of 
the back of a knife-blade, and left on for fifteen or 
twenty minutes. It is then to be wiped off with a soft 
cloth, and the skin powdered with talc. The skin be- 
comes inflamed, turns brown, and peels off. The appli- 
cation is to be repeated every day until the skin does 
peel off. Desquamation can be hastened by the applica- 
tion of Lassar's paste with 2 per cent, of salicylic acid. 

Resorcin has been commended, used in 20 per cent, 
strength dabbed on the face two or three times a day 
until a dermatitis is caused. This is allowed to sub- 
side under cold cream, and when it has subsided the 
resorcin is to be used again. Ichthyol, the ammonio- 
sulphate, is recommended by Unna for acne, either as 
a 3 to 5 per cent, ointment or as a 3 to 10 per cent. 
aqt^^^L solution. As much as 15 grains of it are 
to fee taken by the mouth during the day. A mild 
corrosive sublimate wash is to be applied to the face until 
the patient goes to bed, and then a 10 per cent, aqueous 
solution, or paste of ichthyol, is to be kept on until morn- 
ing. Startin 2 has employed local steam baths by means 
of a steam atomizer, with success. The steaming should 
be kept up for twenty or thirty minutes, and tincture of 
benzoin used in the medicine cup. While useful in some 
cases it does harm in other cases. 

The foregoing remedies are all especially adapted to 
more or less sluggish cases, the type met with in the 
great majority of instances. In very recent and quite 
inflammatory cases, besides the administration of laxa- 
tives and the regulation of the diet, the patient should 
be directed to bathe the face with hot water, either with 

• i Therap. Monatsheffce, 1887, No. 1. 
2 Lancet, 1889, i., 934. 



ACNE. 85 

or without the addition of borax (5ij to Oj), and apply 
a soothing ointment. When the inflammatory symptoms 
subside recourse must be had to some of the above detailed 
methods of treatment. 

Bathing of the face with hot water before the appli- 
cation of any lotion or ointment should be advised. In 
indurated acne, where cutaneous abscesses have formed 
and the lesions are discrete, each abscess will have to be 
opened up with a lancet, the contents of the abscess dis- 
charged, and carbolic acid, either pure or diluted, intro- 
duced, by means of a little cotton around the end of a 
bit of wood, into the abscess cavity, so as to destroy the 
lining membrane. 

Individual acne lesions can sometimes be aborted by 
touching them with pure carbolic acid or acid nitrate of 
mercury. 

The .r-rays have proved curative. The treatment 
should never cause more than a slight erythema. A 
weak light and a soft tube should be used, the patient 
placed at a distance of 8 to 15 inches from the target, 
and exposed for from three to six minutes. Sittings 
may be given once a week for five or six ^veeki, or 
twice a week for from ten days to two weeks and then 
stopped. It is best not to push the raying to the point of 
causing erythema. It is a somewhat dangerous method 
of treatment and should be used only in stubborn cases, 
especially in those leaving scars. The use of the mer- 
curial lamp is also advocated. 

Prognosis. By persistent effort and careful regula- 
tion of all the bodily functions a great improvement can 
be effected, one fairly deserving the name of cure. But 
it is often hard to prevent the occasional appearance of a 
few acne lesions until the period of life in which acne 
usually occurs is passed. There are some cases in which 
we can do but little because we are unable to remove the 
underlying cause. 

Acne, Adenoid. See Lupus miliaris. 
Acne Agminata. See Acne necrotica. 



86 DISEASES OF THE SKIN. 



AcnoAlbida. See Milium. 



Acne Artificialis. By this term is meant an inflam- 
mation of the sebaceous glands and hair follicles caused 
by drugs either applied locally or acting from within. It 
has three principal varieties, namely, tar acne, bromic 
acne, and iodic acne, and should be regarded rather as a 
dermatitis medicamentosa than as an acne. Tar pro- 
duces acne-like lesions with black points when applied 
locally to some susceptible skins. As a rule, papules are 
more abundant than pustules, but abscesses and furuncles 
may form. These lesions are not confined to the usual 
locations for acne, are particularly abundant on the ex- 
tensor surface of the arms, and are recognizable by their 
central black points and by the fact that the patient is 
using tar. For its cure all that is necessary is to stop 
the use of the tar and to soothe the inflamed skin. None 
of these acnes is a true one. Bromic and iodic acne will 
be spoken of under drug eruptions. Derivatives of tar, 
chrysarobin and pyrogallol may also produce similar 
acne-like lesions when applied externally. 

Acne Atrophica is a term applied to the scars left by 
acne, and to acne necrotica. The first needs no descrip- 
tion ; the second will be found further on. 

Acne Cachecticorum is rather to be regarded as a scrof- 
uloderm than an acne, as it probably has little to do with 
the sebaceous glands. It occurs in broken-down or 
scrofulous subjects, and is particularly prone to appear 
upon the extremities, though it may be disseminated over 
the whole body. It takes the form of small, congested 
or dark-red, sluggish, flat papules and papulo-pustules 
that run a slow course, break down, perhaps ulcerate, 
and leave small depressed cicatrices. They may aggre- 
gate into patches. Occurring on the fingers, these will 
often be conjested and clubbed. The lesions may appear 
in crops. It occurs in children as well as in adults. 
It is one of the rare forms of the disease, and requires 
tonic remedies such as cod-liver oil and iron for its cure. 



ACNE. 87 

Acne Cornea. See Keratosis follicularis. 

Acne Fluente. See Seborrhoea oleosa 

Acne Follicularis. See Comedo. 

Acne Frontalis. See Acue necrotica. 

Acne Hypertrophica. See Rosacea. 

Acne, Iodic and Bromic. See Dermatitis medicamentosa. 

Acne Keloid. See Dermatitis papillaris capillitii. 

Acne Keratosa- H. R. Crocker describes this disease 
as an eruption of finger-nail sized, well defined, excoriated 
patches covered with blood crusts located on the cheeks 
and chin, specially near the mouth. It leaves white, 
hard scars. It is usually a symmetrical eruption, but 
the lesions may come out singly or in very small num- 
bers at irregular intervals. The individual lesion begins 
as a red, firm, tender nodule upon which a pustule forms 
and dries iuto a scab. Imbedded in the lesion are one 
or more horny or soft conical plugs about T ^ of an 
inch long, which give rise to irritation until removed. 
When removed the lesion heals slowly after weeks or 
months. The disease is chronic, showing no tendency 
to recovery. Thus far, treatment has been unavailing. 

Acne Medicamentosa. See Dermatitis medicamentosa. 
Acne Mentagra. See Sycosis. 
Acne Miliaris. See Milium. 

Acne Necrotica. Synonyms : A. agminata ; A. frontalis ; 
A. varioliformis ; A. pilaris ; Acne rodens ; A. telangiec- 
todes ; A. ulcereuse ; A. arthritique ; A. miliaire scrof- 
uleuse ; Lupoid acue ; Acnitis. 

The disease begins by the eruption of a few flattened, 
red, firm papules with a red border which in a few hours 
have pale yellow centres looking like pustules, but which 
are crusts. The papules may be the size of a head of 
a pin or that of a lentil. The crusts are 2 to 4 mm. 
in diameter. At first yellow they soon become brown. 
If the crust is raised, it discloses a deep, cup-shaped 
depression with rugose walls. There is a delicate 
layer of pus between the crust and the bottom of the 



88 DISEASES OE THE SKIN. 

depression. Left to itself, the crust falls after many 
weeks, leaving a red, dry depression, which after a time 
becomes white resembling variola scars. If the disease 
occurs on hairy regions it destroys the hair. Sometimes 
the original crust enlarges by the formation of a second 
vesicle about the first, or two vesicles near each other 
may fuse. If scratched, they may become impetiginous. 
The sites of predilection for the disease are the nose, 
temples, forehead, between the shoulder blades, and over 
the breast bone. It is most often seen on the temples 
along the hair, and may spread on the scalp or bearded 
portion of the face, causing destruction of the hair. The 
disease may occur on the limbs. It is not seen before 
puberty, and continues indefinitely or by relapses in one 
place or in several, often symmetrical regions. An oily 
seborrhoea may precede and accompany the disease. 

Etiology. The cause of the disease is not deter- 
mined. It occurs about equally in men and women, who 
usually are over thirty years of age and in poor circum- 
stances. Sabouraud believes that a seborrheal skin is 
the predisposing factor, and that the micro-bacillus is the 
cause of the disease. The staphylococcus aureus is also 
found in connection with it. By some it is thought to 
be due to a tuberculide, the toxins of tubercle bacilli. 

Pathology. J. A. Fordyce l finds that the disease 
begins in and about the hair follicles above the entrance 
of the sebaceous glands. As the inflammatory process 
extends it involves the sebaceous glands as well as the 
superficial portion of the derma, resulting in a necrosis of 
the pilosebaceous system. In one case he found enor- 
mous numbers of staphylococci in the lymph spaces and 
free in the tissues. 

Diagnosis. In some cases the resemblance to syphilis 
is striking, but the extreme chronicity of it and its occur- 
rence along the hair line distinguish it, as well as its 
general course of development. It differs from acne in 

i Journ. Cutan. and Gen. Urin. Dis., 1894, xii., 152. 



ACNE. 89 

leaving varioliform scars, in its sluggish course, and in 
invading the scalp. 

Treatment. The ointment of the ammoniate of 
mercury is efficient in many cases. Sulphur 10 percent., 
salicylic acid, 3 to 5 per cent., and resorcin, 1 to 5 per 
cent, in ointment are also useful. Curetting is of service. 
Sabouraud thinks that for the disease when it invades 
the scalp the best remedy is pyrogallol, either with or 
without tar or sulphur, 15 per cent, in ointment, or 6 
per cent, in ethereal oil. He also advocates the daily 
use of alcohol with a little iodine or bichloride of mer- 
cury for three months after the disease is apparently 
well. Stelwagon has found a lotion of resorcin in a sat- 
urated solution of boric acid best for non-hairy regions, 
conjoined with ammoniate of mercury for hairy regions. 
Crocker speaks highly of the administration of 15 to 25 
drops of chloride of iron three times a day ; and also of 
iodide of potassium. 

Acne Necrotisans et Exulcerans Serpiginosa Nasi is de- 
scribed by Kaposi as an eruption of flabby papules as 
large as a pin's head upon the end of the nose that soon 
undergo purulent or necrotic degeneration and leave deep 
scars. New lesions appear and in a few weeks or months 
the end of the nose is destroyed. 

Acne Pilaris. See Acne necrotica. 

Acne Punctata. See Comedo. 

Acne Rodens. See Acne necrotica. 

Acne Rosacea. See Rosacea. 

Acne Scrofulosorum. See Acne cachecticorum. 

Acne Sebacea. See Seborrhoea. 

Acne Syphilitica. See Pustular syphiloderm. 

Acne Telangiectodes. See Acne necrotica. 

Acne Tuberculide. See Molluscum contagiosum. 

Acne Ulcereuse. See Acne necrotica. 

Acne Urticata is the name given by Kaposi to a chronic, 
itching disease occurring on the face, scalp, hands, and, 
usually, on the extensor surfaces of the extremities. It 



90 DISEASES OF THE SKIN. 

begins as an acute eruption of bean or larger sized, pale- 
red, very hard, wheal-like elevations which within a few 
hours to four days undergo involution. They are usually 
scratched and broken. They leave flat, brown, cica- 
tricial stripes corresponding to the scratches. The itch- 
ing is so severe as to interfere with sleeping. There 
seems to be no good reason for regarding this as a distinct 
disease. It is really a form of urticaria. 

Acne Varioliformis. See Molluscum contagiosum and 
Acne necrotica. 

Acnitis. See Acne necrotica. It has not yet made for 
itself a definite place. 

Acrochordon. See Fibroma. 

Acrodermatitis Chronica Atrophicans. A rare disease 
that begins on the hands and slowly spreads up the arms. 
It begins as small crimson or purplish-red nodules look- 
ing like chilblains, which later become atrophic, thin, and 
wrinkled. Its course is chronic and the treatment 
unavailing. 

Acrodermatitis Perstans. This disease was first described 
by Hallopeau. It always begins upon the ends of the 
fingers as more or less extensive flattened pustules deep 
in the epidermis. Over them the epidermis exfoliates, 
and at last an eroded surface is left. In some cases a 
whitlow precedes them, in some an injury, but many 
come spontaneously. The nails are involved in whole 
or in part. At last the ends of the fingers become 
shrunken, lose their nails, and become little conical, 
sclerosed stumps. From the fingers the disease extends 
upon the palms and backs of the hands. The feet may 
be involved, but less profoundly, and the disease may 
occur elsewhere on the body, although rarely. There 
may be subjective symptoms of moderate pruritus and 
local pain which may be severe and radiate up the arm. 
The disease is progressive and incurable. It is probably 
a neuritis. It occurs both in men and women. 

Acrodynia, or Erythema epidemicum, is a disease closely 



ACTINOMYCOSIS. 91 

allied to pellagra in its symptoms, that has been observed 
chiefly among French and Belgian soldiers, and is 
propably due to some defect in food supplies. It begins 
with gastro-intestinal irritation, to which certain neuroses 
soon add themselves, such as formication, hyperesthesia, 
and anaesthesia. An erythema of the hands and feet, 
and it may be of the whole body, followed by desquama- 
tion or by brown or black pigmentation, is the cutaneous 
element of the disease. Recovery usually takes place, 
although death may occur from diarrhoea. 

Acromegaly. A disease characterized by overgrowth 
of the bones and soft tissues of the face, hands, wrists, 
and feet. It is a rare condition and is allied to elephant- 
iasis. It is a progressive and, usually, symmetrical dis- 
ease, and at times attains immense proportions involv- 
ing the whole body. The skin becomes dry and harsh, 
yellowish and wrinkled. Fibromata may develop. 
Symptoms of nervous derangement are also present. 
The cause is unknown and treatment is of no avail. 

Actinomycosis. While this is usually a disease of cattle, 
in which it causes tumors of the jaws, it may attack man 
and produce nodular tumors with fistulous openings. It 
is due to the invasion of the tissues by the ray fungus. 
Infection usually occurs by the mouth along a carious 
tooth, but it may take place through the digestive tract, 
the lungs, and, rarely, by an abrasion of the skin. The 
incubation period may be weeks, months, or years. The 
tumors bear a strong resemblance to sarcoma and are 
livid or bluish-red. At first firm, they after a time 
soften and break down and discharge through a fistulous 
tract, at first a purulent, afterward a sanious material, in 
which are numerous yellow granules, from pin-head to 
hemp-seed size. They are most often seen on the face 
and neck, but may occur on the chest and abdomen. 
The disease runs a chronic course. Its prognosis is good 
if taken early and properly treated. Otherwise it is 
bad. Iodide of potassium in 10- to 15-grain doses 



92 DISEASES OF THE SKIN. 

three times a day, increased to 30 grains, should be 
given, and continued for some time after the patient is 
apparently well. It may be combined with the inser- 
tion into the sinuses of a 1 per cent, solution of the 
same drug. Sulphate of Copper in J grain dose four 
times a day may be tried. Surgical procedures may be 
resorted to at the same time that the iodide is admin- 
istered. 

Addison's -Keloid. See Morphoea. 

Adeno-carcinoma is a carcinoma originating in the 
glands of the skin, most often in the sweat glands. 

Adenoma. These are glandular tumors, and are due 
to a proliferation of the lining cells of either the sebace- 
ous or sweat glands. There are, therefore, two varieties : 
A. sebaceum and A. sudor iferum. Though met with in 
persons of mature years, it is not improbable that they are 
congeuital defects. They form solid tumors from pin- 
head to egg size, or larger. They may remain stationary 
or grow ; may disappear spontaneously, ulcerate, form 
cysts, or undergo hyaline, colloid, or fatty degeneration. 
While usually benign, they may become malignant. They 
tend to relapse after extirpation. 

The sebaceous form is encountered most often on the 
face, about the nose and mouth ; less frequently upon the 
scalp, but may occur anywhere. While usually symmet- 
rical in distribution it may be unilateral. The lesions are 
rounded papules varying from a pin's point to a split pea 
in size. The color of these adenomata varies from pale 
yellow to red, when they will have fine telangiectases over 
them. They occur most often in women, and in early 
life, are generally multiple, often with an uneven surface, 
and seated deep in the skin. Once having appeared they 
do not tend to change, though a few may undergo invo- 
lution and leave atrophic scars. The patients usually have 
coarse skins, often are mentally deficient, and also fre- 
quently present nsevi, fibromata, and other defects scat- 
tered about the trunk and limbs. They seem to belong 




Adenoma Sebaceum. (Pizzoli.) 



AINHUM. 93 

rather to the class of nsevus than true adenomata. Pol- 
litzer has cured one case of the sebaceous variety by 
means of multiple scarifications. Crocker advises elec- 
trolysis. 

The sudoriferous variety occurs upon the head, neck, 
and extremities as dirty grayish- white tumors, sometimes 
in groups, with uneven, often knobby surface. When 
they develop from the coil they are called adenoma sudo- 
riparum or spiradenoma; when from the duct, syringa- 
denoma. They are rare lesions of the skin, difficult of 
diagnosis, and require extirpation or total destruction for 
their cure. Most cases formerly described under this 
heading are now regarded as cases of multiple benign cystic 
epithelioma, which see. 

Ainhum is a disease most frequently seen in the negro 
race, though a number of cases have been reported from 
India. It is seen in men more often than women, and 
several members of the same family have been known to 
be affected by it. The little toe of one or both feet is 
the one usually diseased, though the other toes do not 
always escape. It begins as a furrow on the inner and 
lower side of the proximal end of the toe, which gradu- 
ally extends outward and upward so as to encircle the 
whole toe at its juncture with the foot. In the mean- 
time the toe becomes enlarged, separates from its next 
neighbor, and rotates outward. When fully developed 
the toe wobbles about so that it interferes with walking. 
The whole process is unattended with ulceration, except 
accidentally caused and after the disease has lasted a long 
time. When it occurs the toe falls off. There is little 
pain experienced till near the end of the disease. It takes 
from one to fifteen years for the full development of 
the disease. The cause is unknown, though traumatism 
probably plays a part. The process is one of progressive 
degeneration and destruction of all the elements of the 
toe — skin, muscles, bone. In its early stage a deep 
incision perpendicular to the direction of the furrow may 



94 DISEASES OF THE SKIN. 

check its course. Later, amputation is required for the 
cure, and healing takes place rapidly. 

Albinism. This is a congenital defect of pigment which 
may be partial or complete. The skin is milky white in 
color, or pinkish. If it affects the hairy parts the hair 
is white or yellowish-white. The pupils of the eyes are 
red, owing to an absence of pigment from the choroid. 
The subjects of complete albinism are not robust. Her- 
edity is a cause. Adrian 1 has found consanguinity in the 
parents in some cases. It occurs both in negroes and 
white people. There is no treatment for the disease. 

Aleppo Boil, Aleppo Bouton, Aleppo Evil, or Oriental 
Sore, is an ill-defined furuncular disease occurring in 
Syria and the Levant, where it is endemic and wide- 
spread. One or more red papules appear that, after 
sometime, change into pea- or bean-sized pustules, grow 
slowly, and ulcerate indolently. Large ulcerating, gran- 
ulating patches may form by the coalescence of neighbor- 
ing pustules. The ulcers are sharply defined and irregular 
in shape, and when crusted may resemble syphilitic rupia. 
Healing takes place after months, leaving a pigmented 
and contracted scar. The disease is painless. In uncom- 
plicated cases the prognosis is good. The extremities 
and face are the parts most often affected. All ages and 
conditions contract the disease. One attack unsually pro- 
tects against subsequent infection. It is due to infection, 
probably by a parasite, called by Wright, " Helcosoma 
tropica." P. G. Woolley 2 recommends J-grain doses of 
sulphate of copper for the treatment of the disease. 
Painting the papules with tincture of iodine is recom- 
mended, as is scraping out the pustules with the curette 
and applying nitric acid. Ulcers are to be treated on 
surgical principles. 

Algidite Progressive. See Sclerema neonatorum. 
Algor Progressivus. See Sclerema neonatorum. 

\ i Dermat. Centralbl., 1906, ix., 258. 

;. 2 Jour. Amer. Med. Assn., 1907, xlviii., 789. 



ALOPECIA SENILIS. 95 

Alopecia. Synonyms: Calvities; (Fr.) Alopecie; (Ger.) 
Kahlheit; (Ital.) Calvezza; (Sp.) Calvez; Baldness. 

By alopecia is meant a partial or general loss of the 
hair, so as to produce a noticeable thinning or a bare spot. 
There are four main varieties, namely : Alopecia adnata ; 
Alopecia senilis ; Alopecia prematura or presenilis ; and 
Alopecia areata. 

Alopecia Adnata is congenital baldness, and is a rare 
affection. 

Symptoms. The newborn child is covered with long, 
dark hair which soon falls to give place to fine lanugo 
hairs ; or this change has taken place before birth, the 
usual course of events, and at birth lanugo hairs only are 
present. In alopecia adnata there is not the slightest 
trace even of lanugo hairs either on the scalp or eyebrows. 
In some cases the baldness is not so complete. Most 
cases, after months or years, recover either altogether or 
partially, but in some cases the hair never grows. In 
pronounced cases delayed dentition or deficiency of the 
teeth has been observed. 

Etiology. The cause of the disease is arrest of the 
development of the hair, probably due to an error in 
innervation. It is said to be hereditary in some families. 

Pathology. There is a complete absence both of 
hair and hair papilla?. There are some abortive hair 
follicles. Otherwise the scalp is normal. 

Treatment. The treatment is mainly an expectant 
one. The nutrition of the child should be looked after 
and the scalp kept in a healthy condition. If this expect- 
ant plan does not satisfy the child's attendants, some of 
the stimulating hair washes, as in alopecia presenilis, 
may be prescribed for the moral effect upon them. 

Alopecia Senilis is baldness occurring in advancing 
years. Any loss of hair commencing about the forty- 
fifth year and without apparent cause may be placed 
under this heading. Graying of the hair may have 
preceded it for several years or may be coincident with 



96 DISEASES OF THE SKIN. 

it. Or the hair may fall without becoming gray. The 
hair fall having once begun is progressive, though its 
rate of progress may be slow or fast. It usually shows 
itself first upon the vertex of the head, forming the ton- 
sure, which slowly increases in size and, moving forward, 
renders the whole top of the head bald. Or it may begin 
anteriorly and move backward. Or the hair on the 
whole top of the head may become thinned at once. 
Rarely are the temporal and occipital regions bald, and 
an island or tuft of hair is sometimes preserved for a 
long time in the middle frontal region. The hair fall is 
always symmetrical and the bare scalp is smooth, oily, 
shiny, and appears as if stretched. Not only does the 
hair fall from the scalp, but it may fall from the axillae 
and pubic region ; these manifestations I believe to be 
more common in women than men. Very rarely does 
the beard fall. 

Etiology. The cause of this form of baldness is a 
progressive atrophy of the scalp. Men are far more 
prone to the disease than are women. 

Treatment. As to the treatment we can do nothing. 
Prophylaxis, as described under Alopecia prematura, 
will delay its onset. 

Alopecia Prematura is baldness occurring before middle 
life. It may be idiopathic or symptomatic. 

Alopecia prematura idiopathica ^arises without any 
evident disease of the scalp or disorder of the general 
health. It usually begins in early life, between twenty- 
five and thirty-five ; it may begin as early as the eight- 
eenth year. Its general course is the same as the senile 
form of alopecia. Very often the upper parts of the 
temples are earliest affected, the hair line receding. In 
those who part the hair in the middle, the thinning of 
the hair about the part may be the first thing to attract 
attention. The process of the hair fall is one of progres- 
sive thinning of the individual hairs at first, and then of 
the whole quantity of hair, so that strong hairs give place 



ALOPECIA PREMATURA. 97 

to lanugo hairs, and these in turn fall and leave bald places, 
At the same time a progressive tightening of the scalp 
upon the skull will be observable in some cases, the scalp 
having lost that cushion of fat that is under it in early life. 
The hair fall having begun is progressive, though years 
may elapse before there is absolute baldness. The ton- 
sure may not enlarge for a long time, and then increases 
rapidly in size. 

Etiology. The main cause of this form of baldness 
is heredity. Fathers and sons for generations may grow 
bald early, or the inherited peculiarity may have to be 
traced to the grandparents or some collateral line. Not 
all the children of one family in which baldness is heredi- 
tary are bald, but it will manifest itself in two or three 
of the children. According to Pincus, 1 inheritance and 
chronic eczema or an impetiginous eruption on the scalp 
in the years preceding puberty are the only predisposing 
causes of baldness. Insufficient or improper care of the 
scalp ; daily sousing of the hair with water, combined 
with improper drying of the hair afterward ; sweating of 
the head, either spontaneously or on account of the wear- 
ing of un ventilated or hot head-coverings ; constant mental 
strain, either on account of intellectual work or of worry ; 
the wearing of stiff, unyielding hats ; gout ; all diseases 
lowering the general nutrition; and dissipation, are all 
put forth by reputable observers as causes of premature 
baldness. 

That women are less often bald than men probably 
depends upon several factors : The fatty cushion beneath 
their scalps is longer preserved than in men ; they give 
more attention to the care of the hair and less often wet 
it ; and their hats are soft, ventilated, and fit loosely. 

Prognosis. The prognosis of this form of baldness 
is bad, and especially so if the disease is hereditary and 
the patient is more than thirty years of age. It is better 
with women than with men, as they will give more time 

1 Virchow's Archiv, 1867, xli., 322. 



98 DISEASES OF THE SKIN. 

to the care of their scalps and show less tendency to 
alopecia. 

Treatment. We can do more for this form of bald- 
ness by prophylaxis than by attempts at making the hair 
that has fallen out grow in again. Prophylaxis should 
begin at the beginning of life, and should be continuous. 
This is of special importance in the case of children in 
families prone to early loss of hair. 

The hygiene of the scalp is the chief part of the prophy- 
lactic treatment. Beginning in infancy, the scalp should 
be gently cleansed of the vernix caseosa and other extra- 
neous substances that have gathered on it during the 
process of parturition. This should be done by the gentle 
use of soap and water after rubbing in a little sweet 
almond or other bland oil. No force should be used, 
and after the scalp is washed it should be patted dry 
with a soft, warm cloth, and a little oil or vaseline 
smeared over it. After the first washing it should be 
oiled daily and washed every second day. When the 
hair begins to grow, a soft brush alone should be used to 
arrange it, and the daily oiling may be stopped, unless 
sebaceous matter accumulates in cakes, in which event 
the oiling should be continued. Sometimes it is well to 
add a little sulphur to the oil or vaseline, but in most 
cases it is unnecessary. The slightest indication of disease 
of the scalp should be promptly and properly dealt with. 
A child's hair should be cut short, not cropped close to 
the head. After a girl has reached her eight or ninth 
year the hair should be allowed to grow. 

The hair and scalp do not need to be washed more 
than once in two or three weeks, and for this purpose 
any good soap will do, with plenty of water to wash out 
the soap-suds. Borax with water will clean the scalp 
nicely, but its continuous use is injurious. The yolk of 
three eggs beaten up with lime-water makes an elegant 
shampoo. The daily sousing of the head in water should 
be prohibited. Deep brushing of the hair with a long- 
bristled brush of sufficient stiffness to warm^ but not 



ALOPECIA PREMATURA. 99 

scratch, the scalp is one of the best agents we have for 
stimulating the scalp. The brushing should be done 
daily and systematically. 

Pomades and hair washes should be avoided unless 
there is some evident disease of the scalp. Women 
should be cautioned against pulling their hair into arti- 
ficial and constrained positions. It is most important 
that a sufficient amount of out-door exercise should be 
taken to aid in keeping the patient in good general con- 
dition. 

When the hair has begun to fall it is important that 
the hygiene of the scalp should be begun, if not already 
practised. We can do more for our cases in this way 
than by any other method. 

Many remedies have been advised for the curative 
treatment of baldness. Pilocarpin, in hypodermic injec- 
tions or in ointment form, has been warmly commended. 
Lassar 1 prescribes it as follows : 

ft. Hydrochlorate of pilocarpin, gr. xxx ; 2 

Vaselin, 3v; 20 

Lanolin, ad ^ij ; ad 60 

Oil of lavender, gtt. xxv. 1 66 M. 

It may alsa be used in the form of the fluid extract of 
pilocarpus, 10 to 15 per cent, strength in dilute alco- 
hol. He also advises oil of turpentine, equal parts with 
an indifferent oil or alcohol. Another useful formula for 
pilocarpin is that of Sabouraud : 



R 



Pilocarpin muriat, 


gr. vij ; 




Aquae rosse, 


3y ; 


50 


Alcohol, 


3vj; 


200 


Spts. etheris, 






Spts. lavendulae, aa 


3vj. 


25 



50 



M. 



This is to be well rubbed in morning and night. It is 
my experience that most of these cases do better with 

1 Therap. Monatshefte, 1888, No. 12. 



100 DISEASES OF THE SKIN 

oily than with alcoholic preparations. Gallic acid 3 per 
cent, in an oily excipieut; tar; galvanism; massage; 
tincture of cantharides (5j-oj), tinture of mix vomica 
(5j-Sj), and a lot of other irritants and essential oils 
have their advocates. My experience teaches me that 
so-called "hair tonics" are of little value, and that the 
best remedies are attention to the general health of the 
patient, massage of the scalp, and daily systematic and 
deep brushiug of the hair. Pilocarpin is the only drug 
that has shown any decided influence on hair growth. 
Electricity is recommended by Stelwagon, either static, 
by means of the crown, quite near the scalp, for five 
minutes ; or faradic, with the metallic brush or comb. 
The high-frequency current, D'Arsonval, is also worthy 
of a trial. It should be used about three times a week, 
with enough vigor to produce redness of the scalp. 

Alopecia prcematura symptomatica is premature bald- 
ness in which there is some evident disease of the scalp 
or disorder of the general nutrition of the body to account 
for it. It has four varieties : Alopecia furfuracea seu 
pityrodes, A. syphilitica, Defluvium capillorum, and A. 
follicularis. 

Alopecia Furfuracea seu Pityrodes is the form most 
frequently met with and the one in which we can often 
obtain good results by treatment. In my experience 
70 per cent, of all cases of loss of hair are of this 
variety. 

Symptoms. In alopecia furfuracea we have an evi- 
dent disease of the scalp to deal with — that is, dandruff. 
By this we mean either a seborrhoea with fatty crusts, 
or else a pityriasis with more or less abundant scaling. 
Both these conditions are now regarded as different 
forms of seborrhoeal dermatitis. 

Alopecia pityrodes has two stages : The first one lasts 
from two to seven years or more, and is attended by a 
greater or less amount of dandruff and by dryness of the 



ALOPECIA FUBFURACEA. 101 

hair. Then comes the second stage, when the hair falls 
more or less rapidly. Its course may be the same as 
that of the two previously described forms of baldness, 
though more commonly the whole top of the head is 
affected at once, the hair becoming progressively thinner 
in diameter and less in amount until baldness results. 
As the baldness increases the dandruff lessens. The 
disease is one of early life in a large number of cases, 
often occurring between the twentieth and thirtieth year. 
While both men and women lose their hair from dan- 
druff, it is quite exceptional for a woman to become 
absolutely bald like a man. 

Etiology. The cause of the hair fall is the dandruff. By 
this it is not meant that everyone who has dandruff will 
become bald. But that in certain persons when the seba- 
ceous glands become diseased, the hair follicles sympathize 
with them, and after a time the hair production ceases. Of 
late the opinion is gaining ground that alopecia pityrodes 
is contagious, and the experiments of Lassar and Bishop i 
would seem to prove this. They succeeded in producing 
typical alopecia pityrodes in guinea pigs by rubbing into 
their backs a pomade composed of the scales taken from 
the head of a student who was afflicted with the same 
disease. A number of observers have reported from 
time to time the finding of a parasite in this disease, but 
as yet no one microorganism can be demonstrated as 
positively at the bottom of the trouble. Sabouraud 2 be- 
lieves that the same parasite that produces the seborrhoea 
produces the loss of hair. It is, accordiDg to him, a 
micro-bacillus that grows down into the hair follicle, 
between its wall and the hair, and causes atrophy of the 
hair papilla. 

Treatment. The treatment of this form of baldness 
must be addressed to the cure of the seborrhoea or pity- 
riasis that causes the loss of hair. Prophylaxis is here 

1 Monatshefte f. prakt. Dermat., 1882, i., 131. 

2 Ann. de derm, et de syph., 1897, viii., 257. 



102 DISEASES OF THE SKIN. 

again more important than the use of remedies for pro- 
moting the growth of the hair. The treatment of sebor- 
rhea and pityriasis will be considered under their respec- 
tive headings, and need not be here detailed. My belief 
is that greasy applications are better than those contain- 
ing alcohol. The mistake is frequently made of pre- 
scribing tincture of cantharides or other irritant because 
the hair falls. Of course, these things, in an already 
more or less inflamed scalp, only do harm. If we 
can succeed in curing the seborrhcea, the hair will take 
care of itself. If the case comes to us before absolute 
baldness is established, we. can feel pretty confident that 
we can stop, or at least delay, the fall of the hair. But 
we must inform our patients that it is only by long and 
persistent treatment that we can accomplish anything. 

Lassar's plan of treatment has gained great currency, 
and is as follows : The scalp is to be vigorously washed 
each day with a tar soap that forms plenty of suds. The 
soapsuds are to be washed out with warm, followed by 
cold, water, the scalp dried and anointed with a solution 
of bichloride of mercury (2 to 1000). This is to be dried 
out by applying 0.5 per cent, solution of /3-naphtol in 
absolute alcohol. Finally, an oil made up of 

Ji Ac. salicylici, £ss; 2! 

Tincture of benzoin, gr. xlv ; 3i 

Neat's-foot oil, ad ^iij ; 100, M. 

is to be applied. The procedure is to be kept up for six 
to eight weeks. I have found few patients who would 
persist in it, and in these I have seen little good result. 
For women it is impracticable. 

Resorcin has been commended. It may be prescribed 
as follows : 

R 



Resorcin, 


gr. xv ; 


3 


01. ricini, 


£ss; 


6 


Spits, vini rect., 


ad £ j ; 


ad 100 


Bals. Peruv., 


gtt. ij ; 


gtt. vj 



M. 
Sabouraud recommends the use of a pomade containing 



ALOPECIA SYPHILITICA. 103 

sulphur, oil of cade, and yellow oxide of mercury on 
three evenings of the week, and on the following morn- 
ings to wash the scalp with soap and water, and rub with 
a brush charged with a 2 per cent, solution of resorcin 
in equal parts of alcohol and ether. 

Tar is a good remedy, but it is objectionable on account 
of its odor and color, ^-naphtol, in 5 to 10 per cent, 
strength, and hydrate of chloral in about the same strength, 
may be tried. Sulphur is the most reliable remedy, 1 
drachm of sulphur to the ounce, and the best way of using 
sulphur is in unguentum aquae rosse or cold cream. If there 
is much pityriasis or seborrhcea the patient should be 
directed to shampoo the scalp and, when it is dry, to rub 
in the sulphur pomade. The next two nights he should 
use a 20 per cent, solution of sulphurous acid in dilute 
alcohol. The next three nights he should use the pomade, 
and then the solution. The scalp should be washed every 
two or three weeks. When this has been kept up for 
three months a pomade of oil of cade 1 drachm in 
the sulphur pomade should be substituted for it to be used 
twice a week. If the smell of the tar is objectionable 
the sulphur pomade alone may be used. Further partic- 
ulars in regard to the treatment of seborrhceal dermatitis 
will be found under the section upon that subject. AVhen 
there is absolute baldness it is questionable if anything 
will make the hair grow. 

Alopecia Syphilitica may be an early or late manifes- 
tation of syphilis ; it occurs both in benign and malignant 
cases, and manifests itself as a more or less general and 
temporary hair fall, or as a localized, destructive, and 
permanent one. 

Symptoms. The former variety occurs early in the 
disease, and is a thinning of the hair in irregularly shaped 
patches scattered over the scalp, giving to it an appear- 
ance similar to what would be produced by cutting the 
hair carelessly with a dull pair of shears. In rare cases 
we may have a general loss of hair from all hairy regions. 



104 DISEASES OF THE SKIN. 

The broken arch of the eyebrow is always suggestive of 
syphilis. There may be some seborrhoea with this form 
of alopecia. 

Localized baldness is one of the later manifestations of 
syphilis, and is always preceded by a destructive disease 
of the scalp. The bald spots will vary in size with the 
extent of the destructive process, which may be one of 
absorption or ulceration. 

Diagnosis. The diagnosis of syphilitic alopecia is 
made by observing the irregular shape of the patches and 
that they are not completely bald, and by the occurrence 
of the broken arch of the eyebrow. These should arouse 
suspicion, when other symptoms of the disease will be 
found. It most resembles alopecia areata, but in this dis- 
ease the patches are perfectly circular or oval and entirely 
bald. 

The baldness due to destructive forms of syphilis can 
be confounded only with that of favus. In the latter dis- 
ease the scalp preserves a reddish color for a long time, 
and then assumes an atrophic, smooth, cicatricial look, 
which is characteristic of it. The history of the two 
cases is very different, as in favus we do not have ulcer- 
ation, and we do have cupped, sulphur-yellow crusts. 
Favus is also more widespread and disseminated than is 
late syphilis of the scalp. 

Treatment. The treatment of this form of baldness 
is that of the underlying disease. A mercurial ointmeut 
or an oil containing the bichloride may aid in hasteuiug 
the new growth of the hair in the early form of baldness. 
The late form may be lessened by active constitutional 
and local treatment, according to the general principles 
laid down for the management of syphilis. 

Defluvium Capillorum is that sudden and general fall and 
manifest thinning of the hair which come on during or 
after some severe illness, such as parturition, fevers, mer- 
curialism, and various cachexia?. 

Symptoms. Rarely does it produce complete bald- 



ALOPECIA AREATA. 105 

ness. The fall is usually rapid and takes place during 
convalescence or after recovery, rather than during the 
course of the disease. It may not occur until three 
months after the illness. Seborrhoea may or may not be 
present. 

Etiology. The cause of the hair fall is the profound 
disturbance of the nutrition of the body, in which the 
hair sympathizes. 

Treatment. The treatment is rather to be addressed 
to the patient than to the hair. If we can succeed in 
building up the patient's strength, the hair will take care 
of itself. The scalp should not be shaved. Local treat- 
ment is the same as in alopecia pityrodes. 

Alopecia Follicularis is balduess due to some disease of 
'the scalp that either destroys the hair follicles or impairs 
the proper performance of their function. A history of 
the causative disease may be obtained, or the disease 
itself will be present. Impetigo; long-continued syco- 
sis ; inflammatory diseases, such as erysipelas ; parasitic 
diseases, such as favus and ringworm ; and destructive 
new growths, such as syphilis and lupus, all may cause 
alopecia follicularis. 

The etiology, diagnosis, prognosis and treatment of this 
form of baldness are the same as the disease that gives 
rise to it, for which we must refer to the proper sections. 

Alopecia Areata. Synonyms : Area celsi ; Area occi- 
dentalis ' diffluens, seu serpens, sen tyria ; Alopecia cir- 
cumscripta ; Porrigo seu tinea decalvans ; Vitiligo capi- 
tis ; Ophiasis ; Phyto-alopecia ; (Fr.) Teigne pelade ; 
Pelade ; (Ger.) Die kreisfleckige Kahlheit ; Circumscribed 
baldness. 

This form of baldness usually begins suddenly, the 
patient discovering by accident, or being told by some- 
one, that he has a bald spot. Sometimes, on waking in 
the morning, the patient is astonished to find loose hairs 
in his bed, and, -on looking in the glass, to see that he 



106 



DISEASES OF THE SKIN. 



has a bald patch on his head. In some cases the hair 
fall may have been preceded for days or weeks by neu- 
ralgic pains in the head. In most people there are no 
premonitory symptoms, and, apart from the bald spots, 
no discomfort on the part of the patient nor cutaneous 
lesions. The neuralgia may continue after the hair fall 
or it may cease. There may be but one bald patch or 
there may be a dozen patches. A patch may be as 
small as a three-cent silver piece or as large as a silver 



Fig. 11. 




Alopecia areata. 

dollar. If larger — and the whole head may be completely 
bereft of hair — the patch is formed by the coalescence of 
several smaller ones. A patch may attain its full size at 
once or it may slowly enlarge, spreading at the periphery. 
The patches are more or less perfectly oval or circular in 
shape and sharply defined against the surrounding hair. 
Patches formed by the coalescence of other patches lose 
the oval outline and may have a scalloped border. The 
color is usually that of the normal scalp ; it may be pale 
or hypersemic. The patch is perfectly bare and smooth, 
without scales, as a rule. Sometimes it is dotted over 



ALOPECIA ABE ATA. 



107 



with short, broken hairs, old roots that soon fall out. 
Sometimes it looks as if it were depressed, an appearance 
due to falling out of the hair roots. Sometimes there is 
more or less seborrheal dermatitis of the scalp. Any or 
all the hairy regions of the body may be affected, the 
patient sometimes being entirely denuded of hair. Most 
often it is the scalp that suffers, especially the temporal 
and occipital regions. The bearded portion of the face 
may be affected alone. Around the border of a recent 

Fig. 12. 




Alopecia areata. 1 

patch the hair is loosened so that it may be readily ex- 
tracted. The sensibility of the skin may be diminished. 
Generally it is preserved. 

The course of the disease is chronic, with a strong 
tendency to spontaneous recovery in anywhere from three 
months to several years. Recovery is heralded by the 
growth of a fine down upon the bald patch. This will 
fall out and be replaced by lanugo hairs that in their 
turn will fall out to be replaced by stronger hairs, until 
normal hairs grow at last, though these at first may be 



By the courtesy of Dr. S. Dana Hubbard. 



108 DISEASES OF THE SKM. 

white. Some cases relapse year after year; in some 
cases the hair never grows beyond the lanugo stage ; and 
some cases remain permanently bald. 

Etiology. The subjects of the disease may be in ap- 
parently perfect health, but not infrequently they are 
of very nervous temperament, exhausted by overwork 
or nervous strain, or out of health in some way. Both 
sexes are affected, the male sex rather more than the 
female. It occurs very often in children. Thus 
Crocker, who has a large experience with children, 
met with it in children under twelve years old in 37 
times out of 83 cases. The youngest case reported 
was two years of age, and cases have been seen as late 
as in the sixtieth year. It is rather more frequent 
among the poor than among the well-to-do. It is more 
frequent in some countries than in others. Thus Crock- 
er's tables show that in London it forms 2 per cent, of 
all skin diseases ; Bulkley's tables show but a little more 
than \ per cent, in New York. 

The disputed points in the etiology of alopecia areata 
are its contagiousness, and whether it is a neurosis or a 
parasitic disease. At the present time it is impossible to 
decide with absolute certainty which of the contending 
parties is right. Most instances of contagion have been 
reported by French observers whose diagnostic skill we 
can hardly call in question. They have reported instances 
in which a large number of cases have appeared in bar- 
racks or schools, and from there spread to neighboring 
towns. In England similar apparent epidemics have 
been reported, but as a fungus indistinguishable from the 
trichophyton fungus was found in the surrounding hairs 
they were doubtless instances of bald ringworm. It is 
possible that some of the French epidemics were of simi- 
lar character. In this country one epidemic apparently 
of alopecia areata has been reported by Putnam. 1 The 
cases were examined by Drs. J. C. White and J. T. 

1 Arch. Pediat., 1892, ix., 595. 



ALOPECIA AREATA. 109 

Bowen, of Boston, who agreed in the diagnosis. Nothing 
suggestive of trichophytosis was found. Isolated in- 
stances of apparent contagion have been reported by 
various physicians. Certainly the body of experience is 
against the contagiousness of the disease. Besnier and 
Doyon, 1 who believe firmly that the disease is contagious, 
think that it is transmitted most often by means of the 
barber's utensils, especially the patent hair clippers, and 
that it is impossible in a great number of cases to trace 
the contagion. Hutchinson and some other English 
authorities are inclined to the belief that in many cases 
ringworm preceded the appearance of the bald spots at a 
greater or less interval. 

As to the parasitic origin of the hair fall, it is not yet 
proven. A goodly number of skilled microscopists have 
described a fungus, but they do not agree among them- 
selves. Still, it is assumed that a microorganism will 
be demonstrated at some time. O. Lassar 2 thinks that 
the phenomenon can be best explained on the theory of 
a virus due to a microorganism. 

This leaves only the neurotic theory. Most derma- 
tologists believe the disease to be a trophoneurosis. It 
has been known to follow blows or injuries to the head, 
moral or mental shock, operations on the neck, and, 
experimentally, injury to or extirpation of the second 
cervical ganglion in cats. Jacquet has asserted that 
carious teeth are in causal connection with many cases, 
and Whitfield would add eye strain and severe infection 
with pediculi capitis. 

Perhaps the disease should be regarded rather as a 
symptom due to a disturbance of the nutrition of the 
hair depending sometimes on microbic infection, at other 
times on a trophoneurosis. For the present no decisive 
answer can be given to the question : " What is the 
cause ? " 

1 Path, et Trait des Mai. de la Peau : Kaposi. French edition, 
Paris, 1891. 
2 Dermat. Zeitschrift, 1900. vii., 809. 



110 DISEASES OE THE SKIN. 

Pathology. Though hairs taken from the margin 
of an advancing area show trophic changes, there is noth- 
ing distinctive about such changes. A. R. Robinson 1 
found e^v idences of inflammation, and some round-cell in- 
filtration confined principally to the perivascular region. 
In recent cases there was a coagulation of lymph in many 
lymphatics, and of fibrin in a few of the large and small 
arteries, with, in old cases, a thickening of their walls. 
In recent cases the hair follicles were either without hair 
or contained a lanugo hair or a hair just about to fall. 
The hair-roots, where present, showed atrophic changes. 
In advanced cases the sebaceous glands were degenerated 
or had entirely disappeared. In the worst cases there 
was complete atrophy of the hair follicles and of the sub- 
cutaneous fatty tissue. He also describes the presence 
of various cocci in the lymph spaces of the corium and 
the walls of a few of the vessels, which he regards as the 
cause of the disease. 

Diagnosis. A typical case of alopecia areata is so 
peculiar that there is little danger of mistaking it for 
anything else. It differs from trichophytosis capitis in 
its sudden onset, its perfectly bare, smooth, non-scaly 
surface, without broken, split, and gnawed-oif hairs, and 
in the absence of the trichophyton fungus from the hair 
and scales taken from the neighboring parts. In bald 
ringworm patches, which resemble alopecia areata, the 
fungus will be found in the neighboring hair, or some 
characteristic " stumps " will be found on the scalp. In 
adults ringworm of the scalp is very rare. It differs 
from favus in the absence of cupped crusts at any time 
in its course, in the scalp not presenting that cicatricial 
appearance always met with in favic baldness, and in 
complete absence of fungus growth. 

The baldness due to syphilis may resemble that of alo- 
pecia areata, but other symptoms of syphilis will be pres- 
ent, and there will never be a history of the formation of 

1 Monatshefte f. prakt. Dermat., 1888, vii., 409. 



ALOPECIA AREATA. Ill 

well-defined oval or circular areas. Lupus erythematosus at 
times affects the scalp and produces circumscribed bald 
areas ; but these are not oval or round, and the skin is red 
and scaly, and evidently cicatrized. The alopecie innomi- 
nee of Besnier is extremely difficult to diagnose from alope- 
cia areata. It differs in not forming regular oval or 
round bald areas, but rather irregular ones, with clumps 
of hair at their borders ; in having a cicatricial appear- 
ance, and in presenting, at first at least, some evidences 
of dermatitis or folliculitis. This type of baldness has 
not yet become well recognized. 

Treatment. In a disease that is essentially self- 
limited it is hard to estimate how much good our reme- 
dies do. One duty we have without peradventure, and 
that is, to look after the general condition of the patient. 
A large number of the cases require a stimulating and 
tonic treatment — iron, quinine, strychnine, arsenic, cod- 
liver oil, or hypophosphites. Children should be taken 
out of school and allowed to run free. Our hardest task 
will be to manage those nervous patients who are ever a 
trouble to us. 

As far as local treatment is concerned, it may be sum- 
med up in two words : patience and stimulation. As 
many of our parasiticides are stimulating to the skin, 
they may be used with benefit whether we believe in the 
parasitic cause of the disease or not. 

The stronger water of ammonia dabbed on the scalp 
several times a day by means of a swab, care being taken 
to guard the eyes, will be beneficial in some cases. It is 
remarkable how little reaction this powerful remedy will 
cause in alopecia areata. Pilocarpi)!, in hypodermic 
injections, or in ointment form, is at times beneficial, 
combined with sulphur ointment and well rubbed in. I 
have seen the hair come back promptly in a few cases 
treated with extract of pilocarpus, 1 drachm in 1 ounce 
of sulphur ointment, and of normal color. Painting the 
scalp with acetic acid until it whitens, and then sponging 
off with cold water, and repeating every three or four 



112 DISEASES OF THE SKIN. 

days; chrysarobin, 15 to 30 grains to the ounce, 
well rubbed into the scalp once a day; carbolic acid (95 
per cent.) applied every two weeks or so to the small 
areas at a time; the bichloride of mercury, 2 to 4 
grains to the ounce in alcohol, or oleum pini sylvestris ; 
the oleate of mercury, in the strength of 2 to 10 per 
cent. ; blistering with cantharides, or 33 J per cent, of 
iodine in collodion ; and galvanism, have one and all been 
followed by the return of the hair. 

Moty 1 reports good results from hypodermic injections 
of bichloride of mercury, injecting 5 or 6 drops of an 
aqueous solution (1 to 500) into many places about each 
patch. In a later number of the same journal he an- 
nounced that he then used a 4 per cent, solution of the 
mercury, with a 2 per cent, solution of cocaine ; that he 
made but a single-drop injection in a medium-sized patch, 
and four or five injections about a large patch, and at its 
periphery. Pauses of four days were taken between the 
injections, and a cure is expected after the fourth series. 
Scheffer 2 is also an advocate of bichloride injections. He 
first rubs the patch with 90 per cent, alcohol. He then 
draws into the syringe \ cc. of 1 to 1000 solution of 
bichloride of mercury; then J cc. of 0.5 per cent, solu- 
tion of pilocarpin ; and then J cc. more of the bichloride. 
He injects this as horizontally as possible beneath the 
skin of the patch at its edge and repeats at one centi- 
metre distance, using about twelve injections for a 
patch the size of a silver dollar. This is repeated in 
four or five days. The hair begins to grow in about 
three weeks. 

Sabouraud 3 advises in single-patch cases cutting the 
hair short, epilating about the patch, and rubbing 
the patch every second day with 1 part of Bidet's 
vesicating liquid and 3 or 4 parts of chloroform. 

i Ann. de derm, et de syph., 1891, ii., 406. 

2 Med. moderne, May 19, 1900. 

3 Diagnostic et traitement de la pelade et des teignes de 1' enfant. 
Paris, 1895. 



ALOPECIA AREATA. 113 

Every morning the whole scalp is to be rubbed with 



ft Alcohol, camphorat., ^iv; 128 

Spts. terebinthinae, §v; 20 

Aquae ammonias, £>j > 4 



M. 



If the patch is very large, instead of the cantharidal 
solution use 



ft Ac. acetici crystal., gr. i-iij ; .065-.194 

Chloral., 3j ; 4 

^Ether., ^ j ; 32 



M. 



From time to time the patch should be shaved as the 
young hairs come in, while the strength and the number 
of applications of the strong solution should be lessened. 
In obstinate cases he applies a blistering fluid at night to 
a limited area, opens it the next morning and paints the 
surface with nitrate of silver solution. The surface is to 
be covered with absorbent cotton. This is to be repeated 
every week. 

Lactic acid in 50 per cent, aqueous solution is highly 
commended by Balzer. 1 Alcohol or ether is to be used 
first to remove the fat from the part, and then the acid is 
to be rubbed in with a tampon until the scalp reddens. 
Use daily. If reaction is too great, omit for a few days 
and use borated vaseline. A cure may be expected in 
from two to three months. 

Trikresol smd alcohol, equal parts, is an excellent remedy . 
After a few days it may produce marked reaction, the 
scalp becoming red and swelling. When this occurs the 
reaction should be allowed to subside under cold cream. 
When it has subsided the trikresol should be again applied. 
It cannot be used in extensive cases excepting in small 
areas at a time. 

Massage is useful. Good results have been obtained 
both by x-rays and phototlierajJi/. In using the former 
great care must be had to avoid burning. Kienbock 2 
advises the use of a medium tube for fifteen minutes at 

1 Monatshefte f. prakt. Dermat., 1900, xxx., 45. 
2 Arch. Derm, et Syph., 1907, lxxiii., 97. 



114 DISEASES OF THE SKIN. 

20 cm. daily for six days. If redness appears, raying 
should be stopped. Both the Finsen apparatus and the 
iron electrode lamp may be used. The latter is specially 
useful. The lamp is to be held about three or four inches 
from the scalp. The time of exposure is five minutes. 
It should be used three times a week. Electricity is 
well spoken of by some ; and the high-frequency current 
is indicated. 

It is advisable to pluck the loose hairs from around 
the patch for a zone of perhaps an eighth or a quarter of 
an inch. Every few days slight traction is to be made 
on the hairs surrounding the patch and all the loose ones 
pulled. 

Prognosis. Even if left to itself, the chances are that 
the hair will grow in again. This good prognosis should 
be guarded when the patient is past middle life and in 
those malignant cases in which there is complete baldness 
that has lasted several years. 

Alopecia Circumscripta. See A. areata. 
Alopecie Innominee. See Folliculitis decalvans. 
Alphos. See Psoriasis. 

Anaesthesia is a loss of sensation in the skin which 
occurs in a number of diseases of the nervous system, 
notably in hysterical affections. It may be general or 
partial, or affect but one-half of the body. There may 
be loss of sensibility to pain while the tactile sense is pre- 
served (analgesia), or intense pain with loss of ordinary 
sensibility (anaesthesia dolorosa). There are many sub- 
stances which, locally applied, will cause anaesthesia, such 
as carbolic acid, cocaine, aconite ; and many others which 
will abolish sensation when taken internally. The subject 
belongs to the domain of the neurologist. 

Anatomical Tubercle. See Tuberculosis verrucosa cutis. 

Angiokeratoma 1 is the name given by Mibelli to a 
peculiar disease of the skin of the hands, feet, and ears 

1 Brit. Journ. Dermat., 1891, iii., 237. 



ANGIOKERA TOM A. 



115 



that has been called telangiectatic warts, or vermes telan- 
giectasiques. 

Symptoms. Angiokeratoma follows chilblains or ex- 
posure to cold, and affects principally the dorsal aspects 
of the hands and feet, though their plantar surfaces may be 
involved to a slight degree and the toes also. A few cases 

Fig. 13. 




Angiokeratoma. (Mibelli.) 

have occurred on the scrotum. The eruption consists in 
tiny, almost imperceptible, pink points that do not disap- 
pear on pressure ; of pin-point to pin head sized darker 
spots that can be made almost to disappear on pressure, 
leaving a deep-red capillary loop in the centre ; and of 
clustered telangiectatic points forming small irregularly 
shaped, slightly elevated groups. These groups may be as 



116 DISEASES OF THE SKIN. 

large as a split pea or bean ; they may project for half a 
line above the surface, are hard, rough, warty-looking, 
and of dull purplish-brown color. Pressure upon them 
brings out the telangiectatic character of the growths. 
When pricked with a needle free hemorrhage takes place. 
The eruption is symmetrical as a rule, and usually affects 
more than one member of a family. It begins in early 
life usually, though it may occur later. It is more com- 
mon in women than in men. There are no subjective 
symptoms. 

Pathology. J. A. Fordyce 1 found in his case that 
the lesions were composed of lacunar spaces filled with 
blood, occupying the papillary portion of the derma. He 
thinks that the vascular changes are primary. 

Treatment. The treatment that proves most bene- 
ficial is destruction by electrolysis. 

Angioma. See Nsevus vascularis. 

Angioma Pigmentosum et Atrophicum is the name pro- 
posed by R. W. Taylor for the xeroderma of Kaposi, 
and is described in this book under Atrophoderma pig- 
mentosum, which see. 

Angioma Serpiginosum. This is a rare disease, of which 
but few cases have been reported. White 2 describes the 
disease as beginning as minute vascular papules that 
slowly increase to the size of a pea and then undergo 
spontaneous involution in the central portions, while they 
spread outward in an annular form to an indefinite extent 
and for an indefinite period. By the end of ten years 
the circinate patches may be no larger than one or two 
inches in diameter. The margin of the rings is elevated 
and of uniform breadth. New foci continually develop 
at a distance of one-eighth to one-third of an inch beyond 
the older areas. These, in turn, are converted into rings 
in the same way. The lesions are firm and smooth and 
are of bright-red to claret color. The centre of the rings 

1 Journ. Cutan. and Gen.-Urin., Dis., 1896, xiv., 81. 

2 Ibid., 1894, xii., 505. 



ARGYRIA 117 

is not elevated, and remains of a dull pinkish-brown tint. 
There are no subjective symptoms. White's case was on 
the right shoulder. Other cases have been on the arm, 
cheeks, and legs. 

Most of the cases develop in early life. They may 
start from a vascular nsevus. The pathology is undeter- 
mined. In White's case the growths were composed 
mostly of endothelial cells and the disease was thought 
to be of sarcomatous nature. Electrolysis or destruction 
by cauterization is to be used in the treatment of the 
disease. 

Angio-Sarcoma. See Sarcoma. 

Anhidrosis or Anidrosis. By this is meant an affection 
of the sweat glandular apparatus attended by a diminu- 
tion or more or less complete suspension of its functions. 
It is a symptom rather than a disease. It may be local 
or general ; temporary or permanent ; symptomatic, as 
in fevers and diabetes ; congenital, as in xeroderma ; or 
neurotic. Some people never sweat perceptibly. In 
certain skin diseases, such as psoriasis, scleroderma, 
squamous eczema, and ichthyosis, the affected areas do 
not sweat. Its treatment is tonic by exercise and bath- 
ing. In symptomatic cases we must strive to remove 
the underlying cause. For congenital cases we can do 
nothing. 

Anonychia means congenital absence of the nail. 
Anthrax. See Carbuncle and Pustula maligna. 
Aplasie Moniliforme. See Trichorrhexis nodosa. 
Area Celsi. See Alopecia areata. 

Argyria is the blue or black discoloration of the skin 
and mucous membranes due to the deposition of particles 
of silver in the rete, sweat glands, and about the hair 
follicles, where it turns black by exposure to the sunlight. 
It used to be seen more often when silver salts were 
administered in the treatment of epilepsy than it is now. 
It occurs also in workers in metallic silver, minute par- 



118 DISEASES OF THE SKIN. 

,ticles of the metal becoming fixed in the tissues. It is a 
permanent staining. 

Arthritide Pseudo-exanthematique. See Pityriasis rosea. 

Asteatosis. Syn.: Xerosis. This is an unnatural dry- 
ness of the skin, which is accompanied by desquamation 
and sometimes thickening, induration, and cracking. It 
is due either to an absolute or relative absence of fat and 
sweat glands, or to the action oi substances that with- 
draw the fat from the skin, such as alkaline solutions. 
It is often seen in old age and in combination with other 
dermatoses, such as ichthyosis. The treatment ol idio- 
pathic cases is by the application of oily substances. In 
cases artificially produced the avoidance of the cause will 
cure the condition. 

Atheroma. See Sebaceous cyst. 
Atrichia. See Alopecia adnata. 

Atrophia Pilorum Propria. Atrophy of the hair exists 
under two forms, namely, Fragilitas crinium and Trichor- 
rhexis nodosa. In both forms the hair shaft is easily 
friable and splits or breaks of itself or by the slightest 
traction. 

Fragilitas Crinium. This disease has been called » 
sura pilorum, and has for its distinguishing feature split- 
ting of the hair. The cleft is usually at the free extrem- 
ity, and at times runs some distance up the shaft. The 
split hairs are either scattered here and there through the 
otherwise normal hair, or all the hairs of the part are 
split. The disease occurs most often upon the hair of 
the scalp, the beard being the place next most frequently 
atfected. It is a common occurrence in the long hair of 
women. The shaft may be split into two or more fibril- 
lse, and these spread out from each other simply or curve 
up upon themselves. The cleft may also occur in the 
middle of the shaft or at its exit from the follicle, and 
in the latter case the shaft will be split throughout its 
entire length, the segments either separating or holding 



ATROPHIA PILOBUM PROPRIA. 119 

together. Duhring x has reported a case occurring in the 
beard in which the hair began to split within the bulb. 
Besides the splitting, the hair may show no other abnor- 
mality, but it is generally more dry and brittle than 
normal, and may be irregular and uneven in its contour. 
The bulb of the hair may be normal or atrophied. 

Etiology. The cause of the idiopathic fragilitas crin- 
ium is yet undetermined. The disease is, without doubt 
due to some interference with the nutrition of the hair, 
probably a yet undetermined trophoneurosis. It is often 
seen in connection with a seborrheal dermatitis of the 
scalp. 

Treatment. When occurring only at the free end of 
long hairs they should be cut above the cleft. In all 
cases the scalp should be kept in good condition, as 
directed under Alopecia prematura. If the disease 
occur in the beard, shaving would at least remove the 
deformity and possibly cure the disease. 

Trichorrhexis Nodosa. Synonyms: Trichoclasia ; Tri- 
choptylose ; Clastothrix. 

Symptoms. The disease most often aifects the hair of 
the beard and moustache, and here it reaches its highest 
development. It is found also on the hairs of the pu- 
bic region and on the scalp hair. Raymond 2 says 
that he has found it on the labia majora in 40 per cent, 
of all women he has examined, and especially in fat 
woman with intertrigo. He has found it also on scrotal 
hairs. It consists of one or more whitish or grayish, shiny, 
transparent nodular swellings occurring along the shaft 
of the hair. In people with red hair the color may be 
black. The number of nodes that may be present is 
from one to five, and their size will vary with the diam- 
eter of the hair. The nodes, according to S. Kohn, 3 
occur usually in the upper third of the hair. These 
nodes give to the hair an appearance not unlike that 

i Amer. Journ. Med. Sci., July, 1878, p. 88. 
2 Ann. de derm, et de syph., 1891, ii., p. 568. 
3Vierteljahr. f. Derm. u. Syph., 1881, viii., 581. 



120 



DISEASES OF THE SKIN. 



Fig. 14. 



produced by the presence of the nits of pediculi. The 
hair is exceedingly brittle and fractures upon slight trac- 
tion or spontaneously, the fracture taking place through 
a node and the hair fibers separating 
like the hairs of a brush. When many 
hairs in the beard are thus broken, their 
frayed-out ends make the beard look 
as if it were singed. Sometimes the 
hair fibers splinter about the node, but 
the two ends do not separate, and this 
gives an appearance like as if two small 
paint brushes were pushed together. 
Sometimes the hair presents an irreg- 
ular contour and looks as if frayed 
along its entire length. While the 
fracture is usually transverse, if there 
should be an exeessive amount of med- 
ulla present in the node, it may be longi- 
tudinal. The hairs themselves are usu- 
ally firmly fixed in the follicles. 

Etiology. The cause of the disease 
may be a microorganism, as microorgan- 
isms have been found in relation to 
the disease by Hodara, Essen, and 
others. E. Spiegler 1 has succeeded in 
cultivating a bacillus and in reprodu- 
cing the disease by inoculation with its 
culture. The parasitic theory of ori- 

In 
many cases it seems to be purely due 
to lack of nutrition. It is by no means rare in the 
long scalp hair of women who are in poor general con- 
dition. Anderson 2 has reported a case of hereditary 
trichorrhexis nodosa, the disease in his patient being 
congenital or nearly so. 



';:■' 






Trichorrhexis nodosa. . . 

(Michelson.) gin is not generally accepted. 



i Arch. f. Dermat. u. Syph., 1897, xli., 67. 
^ Lancet, 1883, ii., 140.] 



ATROPHIA PILORUM PROPRIA 121 

By some it is regarded as purely mechanical, due to 
the patient's habit of handling the board. 

Pathology. The microscopical examination of the 
affected hairs shows that in the early stage of develop- 
ment of the disease there are simply a spindle-formed 
thickening in the continuity of the shaft of the hair and 
a swelling of the medulla, while the cuticle is still intact. 
Later the cuticle becomes cleft, and the cleavage extends 
on all sides of the node until the brush-like appearance is 
produced by spreading of the separate fibers. At the same 
time with the cleaving of the cuticle the medulla under- 
goes degenerative changes. There is either no marked 
change in the appearance of the hair-root or it is slightly 
atrophied. Air-globules are only very occasionally found 
in or about the nodes. Spiegler has found his bacillus in 
the hair beneath the epidermis and in the root-sheath. 

Treatment. The treatment of the disease is very 
unsatisfactory. Continued shaving, followed by a satu- 
rated solution of boric acid, probably offers the best 
hopes. All sorts of applications have been made to the 
affected parts, generally of a stimulating character, par- 
ticularly various forms of mercurials, but without cura- 
tive effect. Gamberini in his work on the hair, recom- 
mends either bathing the part with a lotion composed as 
follows : 

Ji Potass, subcarb, oiij 8 

Alcohol, dil., 

or inunctions of tannic acid or oil of cade. 
Schwimmer advises that an ointment of 



Zinci oxid., 


gr. vij ; 


Sulphur, loti, 


gr. xv ; 


Ung. simp., 


3ijss ; 



M. 

be rubbed in in the morning and evening. 

Besnier finds it useful to pluck the diseased hairs and 
to apply to the newly formed hairs tincture of cantha- 
rides, pure or diluted. Sabouraud advises using daily 



122 DISEASES OF THE SKIN. 



& Hydrarg. bichlor., 


gr. iv; 




20 


Ac. tartaric., 


gr. viij ; 




40 


Resorcin., 


gr. xv-xxx; 


1-2 




Alcohol., 








yEther., 


aa gjss; 


aa 50 


] 



M. 

A 2 per cent, solution or ointment of pyrogallol or 
a 3 per cent, carbolic acid ointment has been advised 
by others. 

Allied to trichorrhexis nodosa we have Monilethrix, 
or ringed hairs, in which the hair shaft is marked by 
alternate swellings and constrictions, the latter being 
colorless. The hairs are liable to fracture through the 
constricted portion, in this way differing from trichor- 
rhexis nodosa. Occurring on the scalp it produces patches 
of hair broken off near the scalp. The disease has been 
met with on the legs. It is probably due to a tropho- 
neurosis. Heredity is a prominent etiologic factor. It 
usually begins in infancy. Keratosis pilaris is com- 
monly present. It has been known to follow nervous 
shock. It begins in the hair follicle. Treatment is 
unavailing. 

Atrophia Unguium. Atrophy of the nails occurs as a 
symptom of very many diseases of the skin, such as 
lichen ruber acuminatus, pityriasis rubra, psoriasis, and 
syphilis ; or it may be caused by the invasion of the nail- 
bed by parasites, as in favus and ringworm. It may 
also occur like detluvium capillorum as a sequence to 
some grave acute illness, such as typhoid fever or scar- 
latina, or some cachexia, such as diabetes. The nails 
may be congenitally absent or deficient, or become so 
without apparent cause. Injuries and certain chemicals 
will cause the nails to atrophy and fall. Atrophy is 
shown by white spots in the nails, by loss of lustre, by 
tranverse white lines, by longitudinal or transverse fur- 
rows, by a worm-eaten appearance, or by a general thin- 
ning and breaking away of the nail-plate. 



ATROPHODERMA. 



123 



Treatment. The treatment is most unsatisfactory. 
If the cause can be discovered and removed, the nails 
will recover. In many cases all we can do is to protect 
the nail by rubber cots or by the use of wax or other 
protective. Ointments of lead, zinc or mercury may be 
rubbed in. The persistent use of sulphur ointment, 
combined with the administration of arsenic, will prove 
beneficial in those cases apparently dependent upon nerve 
disturbance. 

Atrophoderma, or Atrophia Cutis. Atrophy of the 
skin may be quantitative or qualitative ; idiopathic or 
symptomatic ; diffused or circumscribed. Crocker 1 gives 
this useful table : 



Atrophoderma 
Idiopathicum. 



Atrophoderma. 
Symptomaticum. 



DiffusUm 



f Juvenilis 
\ Congenitalis 
[Senilis 



Circumscriptum 
(striae et maculae] 

Neuriticum 

(glossy skin) 



Morborum cutis. 



< Pigmentosum. 
( Albidum. 
J Quantitativum. 
(Qualitativum. 

j Traumaticum. 

1 Non-traumaticum. 

f Traumaticum. 

I Non-traumaticum. 

Scleroderma. 

Seborrhcea. 

Lupus. 

Syphilis. 

Favus, etc. 



The symptomatic atrophies will be spoken of under 
their proper headings. The other forms of atrophy will 
be considered here. 

Atrophoderma Pigmentosum. Synonyms : Xeroderma 
pigmentosum (Kaposi) ; Angioma pigmentosum et atro- 
phicum (Taylor); Dermatosis Kaposi (Vidal); Liodermia 
essentialis cum melanosi et telangiectasia (Neisser) ; Mel- 
anosis lenticularis progressiva (Pick); Lentigo maligna 
(Piffard) ; Epitheliomatose pigmentaire (Besnier). This 
is a very rare disease of the skin, first described by 



Diseases of the skin. Lond. and Phila. , 1905. 



124 DISEASES OF THE SKIN. 

Kaposi in 1870 under the name of xeroderma, to which 
he subsequently added the adjective pigmentosum. It 
is a congenital disease ; almost all cases begin before the 
second year of life. 

Symptoms. It affects the parts most exposed to the 
air ; the face, neck, chest, and back down to the level of 

Fig. 15. 




Atrophoderma pigmentosum. (After Crocker.) 

the clavicles, or even the third rib, the backs of the 
hands, forearms, and upper arms. The hands, face, and 
neck are most markedly diseased, while few cases have 
occurred upon the scalp, legs, and back of the feet. 
It begins with erythematous patches, like those produced 
by sunburn. After a time brown or black freckle-like 
spots form upon the erythematous ones. They are from 
pin-head to bean size and round or irregularly shaped. 
Small red spots appear among the pigmented lesions, 



ATROPHODERMA PIGMENTOSUM. 125 

which Taylor thinks are their forerunners. The pig- 
mented spots in time give place to white atrophic ones, 
and the skin becomes too small for the underlying parts, 
so that it appears drawn and in some places bound down. 
A fully developed case presents a vast number of lentig- 
inous spots interspersed with white atrophic spots and 
stellate and striated telangiectases. After a time, on 
account of the atrophy of the skin, we find ectropion, 
thinned alee nasi, and contracted nasal and oral orifices. 
There may be white atrophic spots on the mucous mem- 
brane of the lips. Conjunctivitis generally supervenes 
upon the ectropion, and the discharge from the eyes sets 
up ulcerations which in their turn give rise to other 
ulcerations. Warty growths at last appear, and these 
are prone to take on malignant action and be con- 
verted into epitheliomas, the patient dying at an early 
age from marasmus, although in some cases the course 
of the disease is prolonged for ten, twenty, or thirty 
years. At first, however, there is no disturbance of the 
health. 

Etiology. The etiology of the disease is obscure. 
It is supposed by some to have its starting point in irrita- 
tion of the skin by the sun or other irritant. Many of 
the cases begin in the summer. It is supposed by others 
to be a trophoneurosis. It is found in both sexes, but 
is peculiar in affecting several members of the same 
family and of the same sex, and in beginning in the first 
or second year of life. It may be hereditary. In a few 
of the cases there was a history of cancer in the family. 
Thus far microscopical investigations have failed to throw 
light on the pathology of the disease. 

Diagnosis. The disease is to be differentiated from 
scleroderma by the peculiarity of its being limited to 
exposed parts, by lacking stony hardness, by occurring 
early in life, and by the general picture of pigmented 
and atrophic spots and telangiectases being intermingled. 
It differs from urticaria pigmentosa in not itching, in not 
occurring upon the trunk, in the absence of wheals, and 



126 DISEASES OF THE SKIN. 

in the presence of telangiectases and warty or epithelio- 
matons growths. 

Treatment. Nothing has yet been found to stop the 
progress of the disease. The conjunctivitis is to be cared 
for, the ulcerations on the face healed as rapidly as pos- 
sible, and the warty growths and epitheliomatous nodules 
destroyed at an early date so as to prevent the develop- 
ment of epitheliomatous or carcinomatous ulcers. A 
saturated solution of boric acid will do much for the eyes ; 
the ulcers may be treated with iodoform or aristol powder 
or a dilute ammoniate of mercury ointment; while the 
warty growths should be scraped off with a curette. The 
aj-ray may be used as in epithelioma for the healing of 
the ulcers. 

Prognosis. The disease is fatal, death from marasmus 
taking place in from ten to twenty years. 

Atrophoderma Albidum is the name used by Crocker for 
a second form of the xeroderma pigmentosum of Kaposi, 
which is described by the latter as beginning in child- 
hood, affecting most frequently the lower extremities and 
less often the forearms and hands, and characterized by 
thinness of the skin, which in some places is stretched and 
cannot readily be taken up into folds. The color of the 
skin is pale and white, with a delicate rosy shimmer in 
places, and here and there its epidermis peels off in asbes- 
tos-like lamellae. The treatment is simply protective. 

Atrophoderma Idiopathica Diffusa. Diffused idiopathic 
atrophy of the skin is a very rare affection. It may be 
congenital or acquired, general or partial. The subcu- 
taneous tissue disappears, so that the skin lies close to the 
underlying parts. It is thin, pale, stretched or wrinkled, 
easily movable over underlying parts and allows the blood- 
vessels to show through. In some cases thick scaly plates 
form, while in others these are wanting and there is only 
slight scaling. The elasticity of the skin is lost, so that 
if it is pinched up into folds these slowly flatten out. In 
some cases the skin seems too small for the body, which, 



ATROPHODERMA SENILIS. V21 

on the face, gives rise to ectropion and other deformities. 
The sensibility of the skin may not be diminished. The 
patients are susceptible to cold. Ulcers are prone to form 
upon slight injuries. The hair is destroyed. The disease 
is probably a trophoneurosis. By some observers it is 
thought that a faintly marked inflammatory process may 
be the starting point of the disease. One case was ascribed 
to exposure to cold. 1 

Hardaway 2 reported two cases occurring in a brother 
and sister; and Ohmann-Dumesnil 3 has met with a case 
of atrophy of the skin and muscles of the right arm 
apparently following an injury to the radial nerve by 
means of a burn on the hand. 

One variety of diffused idiopathic atrophy of the skin 
is that called hemiatrophia facialis j^'ogressiva, in which 
only one-half of the face is affected, and the skin becomes 
thinned and shrunken so that it lies close to the bones. 

Under this heading may also be placed the glossy sJcin 
of Paget, Weir Mitchell, and others. It commonly affects 
the fingers, less often the extremities, and follows upon 
disease or injury of nerves. It occurs also in scleroderma. 
The fingers become dry, red, or mottled, look glazed or as 
if varnished, and are shrunken. The natural lines of the 
skin disappear and the nails fall off. If parts covered 
with hair are affected, the hair falls. Its tendency is to 
spontaneous recovery. 

Atrophoderma Senilis is a true atrophy of the skin that 
takes place in consequence of advancing years. Other 
degenerative changes also are present, as a rule. It may 
be partial or general. The skin looks wrinkled; it is 
thrown into folds, is dry and sometimes scaly, and is often 
of darker color than normal. By pinching up the skin 
the thinness of it is readily appreciated. With the atrophy 
of the skin there are likewise loss of the subcutaneous fat, 

iPospelow; Ann. de derm, et de syph., 1886, vii., 505. 
-Trans. Amer. Dermat. Assoc, 1884. 
3 Alienist and Neurologist, July, 1890. 



128 DISEASES OF THE SKIN. 

pruritus, and verruca senilis. Treatment is out of the 
question. 

Atrophoderma Striatum et Maculatum. By this is meant 
circumscribed atrophic streaks or spots. They may be 
idiopathic or symptomatic. The idiopathic form is far 
more rare than the symptomatic form. 

Symptoms. The idiopathic streaks are met with most 
often about the thighs, buttocks, and lower anterior part 
of the abdomen. They are one or two lines wide, slightly 
curved, and from one to several inches long. There are 
usually several present and then they are arranged parallel 
to one another and run in an oblique direction. The 
macules are isolated, from pinhead to finger-nail size or 
larger, occur most frequently on the extremities and lower 
part of the trunk, but may occur as high up as the neck, 
and are less common than the streaks. Both forms of 
lesion are depressed below the surface of the skin, and are 
of a pearly or bluish-white color and have a glistening, 
scar-like appearance. They are not primary atrophies, 
but succeed to an erythematous hypertrophic lesion, in 
this greatly resembling morphoea. They give rise to no 
inconvenience, and are accidentally discovered. They 
usually are permanent, though they may become less pro- 
nounced in time. 

Etiology. The etiology is obscure. By many it is 
regarded as a trophoneurosis. Shepherd 1 and Duck- 
worth 2 have reported cases of atrophic spots and lines 
following fevers. 

Symptomatic lines and macules are very common, and 
are caused by the stretching or rupture of the more super- 
ficial bundles of white and elastic fibrous tissues of the 
skin. If the fibres are ruptured, the striae will be most 
pronounced, and there will be little left of the skin but 
the epidermis and a thin fibrous membrane. 3 This form 
of atrophy of the skin is seen upon the abdomen of 

i Trans. Amer. Dermat. Assoc, 1890, p. 23. 

-Brit. Journ. Dermat., 1893, v., p. 357. 

3 Taylor, R. W. : New York Med. Journ., 1886, xliii., p. 1. 



BLACKHEADS. 129 

pregnant women (linece albicantes) and on the breasts of 
nursing women. It has also occurred about the joints in 
young people who have grown rapidly after being con- 
fined in bed Avith an illness such as typhoid fever. In 
fact, anything that greatly distends the skin may give rise 
to them, such as abdominal ascites, obesity, ovarian or 
other tumors. 

Treatment. The treatment of these cases is purely 
expectant. Both the idiopathic and the symptomatic 
atrophies may grow less pronounced in time. 

Aussatz. See Leprosy. 
Autographism. See Urticaria factitia. 

Baelzer's Disease of the lip is a chronic affection of the 
mucous glands of the lip marked by an indolent swelling 
and infiltration of the periglandular tissue, and a slow 
ulceration from above downward. It ceases only with 
the destruction of the affected gland. The neighboring 
lymphatic glands are not implicated. A superficial catar- 
rhal inflammation of the mucous membrane of the lips 
frequently accompanies the process. There is no general 
systemic disturbance. It has no relation either to syphilis, 
tuberculosis, or cancer. It is regarded as a local infection. 
It is readily cured by the application of tincture of 
iodine, which at first is used every other day, and later 
every day. 

Baker's Itch.. See Eczema. 
Baldness. See Alopecia. 
Barbadoes Leg. See Elephantiasis. 
Barber's Itch. See Trichophytosis barbae 
Bazin's Disease. See Erythema induratum. 

Beigel's Disease is a parasitic growth found on false hair, 
marked by the appearance of dirty-brown nodes on the 
hair shaft. It is a fungus of yet undetermined species 

Birth-mark. See Xasvus. 

Biskra Bouton, or Biskrabeule. See Aleppo boil. 

Blackheads. See Comedo. 



130 DISEASES OF THE SKIM 

Black Tongue. Black Tongue, Hairy Tongue, or Hyper- 
keratosis linguae. According to Stel wagon/ this disease 
is most often located on the dorsum of the tongue in 
front of the circum vallate papillae, but may occur in 
front of this region. The color is usually black, but 
may be yellow, or blue. There may be simply discolor- 
ation, but more usually fine hair-like projections spring 
from the darkened patch. The disease may develop rap- 
idly or slowly, to areas of varying size. After lasting 
for weeks, or years, it usually disappears of itself. It 
gives rise to no subjective symptoms as a rule, excepting 
a mawkish taste, and rarely, slight pain. 

The cause of the disease is unknown. It occurs both 
in children and adults, and in both sexes. Attention to 
the hygiene of the mouth and the use of an antiseptic 
mouth wash are the means for treatment. 

Blasenausschlag. See Pemphigus. 
Blastomycetic Dermatitis. See Dermatitis blastomy- 
cotica. 

Blutfleckenkrankheit. See Purpura. 
Blutgeschwiir, or Blutschwar. See Furunculus. 
Blutschweiss. See Hsematidrosis. 
Boil. See Furnuculus. 

Botryomycosis Hominis. This is probably only " proud 
flesh" and due to staphylococcus aureus ; though by some 
it has been thought to be caused by botryomyces. It is 
characterized by pedunculated rounded pea to nut-red 
tumors with a more or less mammillated surface. They 
are soft and elastic to the touch, and sometimes bleed 
easily. Usually there is only one lesion. They are most 
often seen on the hands but may occur anywhere. They 
usually start from a slightly injured surface which has 
suppurated. They consist of a connective tissue stroma 
and granulation tissue. The epidermis over them is 
wanting either wholly or in part. They should be tied 
or cut off, and dressed with antiseptics. A better name 

1 Diseases of the Skin, Phila., 1907. 



BROMIDROSIS, 131 

for them is that proposed by Crocker, granuloma pyogen- 
icum. 

Bouton d'Amboine. See Yaws. 

Brandrose is a phlegmonous erysipelas. 

Bricklayer's Itch. See Eczema. 

Bromidrosis- Synonym: Osmidrosis. This word means 
stinking sweat, which, though not elegant, is expressive. 
It most often affects the feet, and then is associated with 
hyperidrosis. It may be general, as in the negro race. 
The odor is not necessarily repulsive, a few cases having 
been reported in which it was that of violets. The 
axilla? are, next to the feet, the most common site of the 
trouble. The odors of different fevers and cachexia? are 
usually classed under this heading, although they do not 
properly belong here. 

Strictly speaking, bromidrosis should include only 
those rare cases in which the sweat, when secreted, has a 
distinctive odor. Usually the odor in bromidrosis is not 
in the sweat, but in the products of decomposition, the 
fatty acids and the like. When the feet are the parts 
affected they will be found to be of a pinkish color about 
the soles and between the toes, or the skin will look 
sodden and grayish. When the hyperidrosis is well 
marked, and it commonly is, the feet may be so tender 
as to interfere with locomotion. The stench from a 
pronounced case is such that it is almost impossible to 
stay near the subject of the disease. 

Etiology. The cause of general bromidrosis is either 
inherent in the race or unknown. Most of the cases, 
apart from the racial ones, have been in hysterical sub- 
jects. In the usual form of the disease it is due to 
decomposition of the sweat in the stockings, shoes, or 
clothing of the individual. When the part is uncovered 
and kept clean, there is no odor. Thin has described a 
parasite, that lie has named bacterium foetidum, as the 
cause of the disease. It is supposed that this bacterium 
can live only in an alkaline medium. The sweat is acid, 
and, therefore, on most feet it does not grow, but when 



132 DISEASES OF THE SKIN. 

hyperidrosis macerates the epidermis and allows of the es- 
cape of serum the acidity of the sweat is neutralized and 
the bacterium flourishes. 

Treatment. The treatment of the general cases is of 
no effect. In the local cases the hyperidrosis is to be 
overcome, as will be described in its proper place. The 
special treatment directed to the cure of the odor of the 
feet is to wash them with soap and water two or three 
times a day, to put on a clean pair of stockings every 
morning, to ventilate the shoes thoroughly, and to dust 
the feet, between the toes, the stockings, and the inside 
of the shoes with finely powdered boric acid. Thin 
recommends the wearing of cork inside soles, which are 
to be soaked in a saturated solution of boric acid and 
dried before using. Another useful powder is : 



R Ac. salicylici, gjss-iij ; 5-10 

Pulv. alum, exsic. vel. | ad _. ad 

Pulv. lycopodn, f ° J ' 



M. 



to be applied in the same way, twice a day. This will 
cause the skin to exfoliate, when the treatment may be 
stopped. 

W. Osier 1 reports one case of general bromidrosis cured 
by the administration of alkalies. 

Bucnemia Tropica. See Elephantiasis. 

Bulpiss 2 is a disease that occurs in Nicaragua, affecting 
every tribe, both sexes, and all ages, though rare in early 
infancy. It begins on the feet and hands, and spreads 
gradually, or upon the knees, or abdomen, or neck and 
face. Two kinds are described. In the white bulpiss 
there are crops of minute reddish papules, which on 
disappearing leave discolored spots. After a time the 
pigmentation fades away and leaves a dirty white, round 
or oval patch, with slightly elevated and partly dis- 
colored broad margins. In black bulpiss the patches are 
grayish black, and the skin is dry and shrivelled. Both 

1 Montreal Med. Journ., 1896-9, xxv., 890. 

2 O. Lerch: New Orleans Med. and Surg. Journ., 1894-5, xxii., 793. 



CALLOSITAS. 133 

kinds itch at night. It is contagions and probably par- 
asitic. It resembles if it is not identical with caraate. 

Bunion. According to P. Syms, 1 a bunion is always 
secondary to an outward displacement of the first phal- 
anx of the great toe due to ill-fitting shoes. As a result 
we have a periostitis with hyperplasia, and finally exos- 
tosis of the metatarsal bones. The pressure between the 
exostosis and the shoe gives rise to an inflamed bursa, the 
bunion. Surgical interference and properly constructed 
shoes are the only remedies. 

Cacotrophia Folliculorum. See Keratosis pilaris. 
Calculi, Cutaneous. See Milium, 

Callositas. Synonyms : Callosity ; Callus ; Tylosis ; 
Tyloma ; Keratoma ; (Fr.) Durillon. This is familiar to 
all as the callous skin of the hands met with in oarsmen, 
blacksmiths, and in those who follow other manual occu- 
pations, and is a hypertrophy of the epidermis consequent 
upon intermittent pressure of the skin against the under- 
lying bone. Constant pressure will cause atrophy. The 
same thickening of the skin is found upon the soles also, 
due to going barefoot or wearing improperly fitting shoes. 
This form of the disease is not infrequently met with in 
people who are past middle life, and sometimes is due to 
a flattening of the arch of the foot. In fact, it may 
develop^ anywhere under proper conditions. 

Treatment. Cessation from using the hands will be 
followed in course of time by the disappearance of the 
callus. To hasten its removal we may use maceration 
with rubber cloth continuously applied to the part, or 
soaking in hot water containing J to 1 ounce of carbonate 
or bicarbonate of soda to the gallon. Or a plaster of 
salicylic acid, or a solution of salicylic acid 10 to 20 per 
cent, in ether or collodion. The action of these remedies 
will be aided by previously paring down the part with a 
sharp knife. AYhen the soles of the feet are affected spe- 
cial attention must be given to the shoes, and to rectifying 

1 New York Med. Journ., 1897, lxvi., 448. 



134 DISEASES OF THE SKIN. 

any flat foot by mechanical means. Salicylic acid plaster 
and the daily soaking of the feet are the best local ap- 
plications. 

Callus. See Callositas. 

Calvez -\ 

Calvezza r See Alopecia. 

Calvities J 

Cancer. See Carcinoma and Epithelioma. 

Cancroide. See Epithelioma. 

Canities. Synonyms : Trichonosis cana ; Trichonosis 
discolor ; Poliothrix ; Poliosis ; Trichonosis poliosis ; Spi- 
losis poliosis ; Poliotes ; Grayness of the the hair ; White- 
ness of the hair ; Blanching of the hair ; Atrophy of the 
hair pigment. 

Grayness or whiteness of the hair maybe congenital or 
acquired ; the latter is by far the most common. The 
whiteness is either partial or complete. 

Congenital canities usually occurs in the form of tufts, 
sometimes in round patches, the more or less pure white 
hair showing conspicuously among the normal-colored 
mass. When the whiteness is general Ave have albinism, 
which is associated with a deficiency of pigment in the 
whole body. Cases of congenital canities are rare. 

Acquired canities may be premature or senile. Most 
often grayness does not begin before the thirty-fifth or 
fortieth year. If it occurs before this age, it may be con- 
sidered as premature ; and when after this age as senile. 
Premature canities is by no means uncommon, many per- 
sons becoming gray between the twentieth and twenty- 
fifth year. The hair which first whitens is, as a rule, 
that of the temples ; then follows, with more ot less 
rapidity, that of the vertex and whole head. Some- 
times the beard first turns gray, but usually it changes 
color after the hair of the scalp. The last hair to become 
gray is that of the axillae and pubis. When the gray- 
ing is due to some passing cause, as anxiety or some 
diseased state, the process may cease completely upon 
removal of the cause. Usually the whiteness is perma- 



CANITIES. 135 

nent. As a rule, there is uo change in the color of the 
scalp, although in some cases gray tufts are found upon 
pale-yellow patches of the scalp. As in alopecia, so in 
canities, men are more frequently affected than women. 

The hair in canities is usually unchanged except in 
color, but it may be drier and stiffer than normal. Cani- 
ties may exist for years without alopecia. 

The hair turns gray first at its root. The color at first 
is gray on account of the mixture of the normal color 
with the whiteness due to the absence of pigment. Grad- 
ually, the white parts gain the ascendant, and the whole 
hair is blanched, becoming finally of a yellowish or 
snowy whiteness. The darker the hair is originally the 
more it is prone to turn gray. 

Sudden change of color of the hair from its normal 
hue to perfect white has been too well authenticated to 
allow of a doubt as to its occurrence, though it has been 
denied by good authorities, who have questioned the 
correctness of the observations reported. 

Ringed hair is an anomalous variety of blanching of 
the hair in which the affected hairs are marked by alter- 
nate rings, one being that of the normal color, and the 
next white. The occurrence of this disease is very rare 
and but few cases have been reported. 

The hair has been known to lose its color under vary- 
ing circumstances. Very commonly the first hair that 
comes in after alopecia areata is white. Wallenburg l 
reports a case in which, after an attack of scarlatina, the 
patient's brown hair was entirely lost and replaced by a 
growth of white hair. Prolonged residence in a cold 
climate, with much exposure, will cause the hair to turn 
gray. Sometimes the hair will change its color with the 
season, becoming gray in winter and darker in summer. 
On the other hand, Cottle 2 gives prolonged residence in 
hot climates, with much exposure, as a cause of canities. 
Albinoes, we know, are most frequent in the negro races, 
which inhabit the hot countries. 

1 Vierteljahr. f. Derm. u. Syph., 1878, iii., 63. 

2 The Hair in Health and Disease. London, 1877. 



136 DISEASES OF THE SKIN. 

Etiology and Pathology. Senile canities and 
many cases of the premature form are due to an obscure 
change in the nutrition of the hair papillae which inter- 
feres with the production of pigment. Only this func- 
tion of the papillae seems to be interfered with, as the 
hair-forming function is in full activity, judging from 
the fact that the hair in many cases is in full vigor. In 
cases of sudden blanching of the hair the change of color 
is dependent upon the formation of air bubbles between 
the hair cells of the cortical substance, the presence of 
the air rendering the cortical substance opaque, so that 
the color of the pigment is obscured. There are various 
agents which act as active or exciting causes of canities. 
Age is one of the most prominent of these. Heredity ex- 
erts marked influence upon the blanching of the hair, most 
of the members of certain families turning gray at an 
early period of life. Neuralgia of the fifth nerve, dys- 
pepsia of various forms, sudden fear or nervous shock 
(producing sudden blanching of the hair), profuse and 
frequent hemorrhage, excesses of all kinds, chronic de- 
bilitating diseases (as syphilis, malaria, and phthisis), 
local diseases or injuries to the scalp, as wounds, favus, 
repeated epilation, prolonged shaving, and the like, have 
been given by various writers as causes of canities. 
Schwimmer regards it as being principally a tropho- 
neurosis, and finds in the occurrence of grayness in the 
course of neuralgia a strong argument for his theory. 

Treatment. We cannot restore the color to gray 
hairs. In some cases of canities occurring in the course 
of neuralgias, if we can cure the neuralgia, the color will 
gradually return to the hair. 

Besnier and Doyon suggest the use of acetic acid as a 
promoter of pigmentation, as they have seen numerous 
instances of its use in alopecia areata followed by growth 
of hyper-pigmented hair. 

All that can be done for canities is to restore artifi- 
cially the color by means of hair dyes, and their use is 
to be deprecated. Happily the custom of dying the hair 
is falling out of fashion. 



CARBUNCLE. 137 

Caraate. See Pinta. 

Carbuncle. Synonyms: Anthrax, 1 Carbunculus; (Ger.) 
Bran dsch war. 

A phlegmonous inflammation of the skin and subcu- 
taneons tissue, attended with sloughing. 

Symptoms. The disease begins as an innocent-look- 
ing papule, which, however, is far more painful, both 
subjectively and objectively, than an ordinary papule 
would be. Within twenty-four hours it becomes larger, 
more painful, slightly raised and reddened, and is gen- 
erally accompanied by a good deal of constitutional dis- 
turbance, such as chills, fever, and nervous irritation. 
All the symptoms increase in severity, the inflammation 
extends laterally and vertically, the swelling becomes 
darker in color, the pain more intense, throbbing, and 
lancinating;, and the constitutional disturbance may be 
so severe that the patient is compelled to go to bed. 
Within ten days, or perhaps longer, the swelling has 
reached its height. It may be two or three inches or 
more in width, with a brawny base that is more or less 
sharply defined, of irregular shape, firm to the touch, 
and with a wide area of (edematous skin about it. Now 
it begins to soften, not like a boil with a central point, 
but with the formation of a number of pea-sized purulent 
points, through which sanious pus exudes, giving to the 
surface a cribriform appearance. Sloughing takes place 
through the openings, that gradually enlarge, so that at 
last there results an irregular, deep, excavated ulcer with 
firm, sharply cut, everted edges. In very bad cases the 
whole mass may fall out at once. The ulcer gradu- 
ally fills up, heals, and leaves a scar. With the dis- 
charge of the slough the patient gradually recovers his 
health ; but in some cases, especially in persons already 
debilitated or in elderly people, the disease runs a fatal 
course, the patient dying of exhaustion or pyaemia, or the 

1 Anthrax, a term that is often applied to carbuncle, should be 
used rather for malignant pustule or the local manifestation of 
splenic fever. 



138 DISEASES OF THE SKIN. 

disease runs into a typhoid condition preceding death. 
Death may also result from acute sepsis, or from throm- 
bosis or embolus, especially in carbuncles en the scalp. 
In some cases the resulting ulceration is very large, with 
a corresponding amount of general disturbance of the 
system. Dry gangrene may take place. 

The disease is rare in children, and most common in 
middle and old age. Men suffer more often than women. 
The most frequent locations of the disease are the upper 
dorsal region, back, buttocks, and forearms, although it 
may occur anywhere. It is usually a single lesion. The 
duration of the whole process is six weeks or more. 

Etiology. The causes of the disease are very much 
the same as those of boils. While carbuncle is most apt 
to occur in those who are not in good health, it does 
occur at times in apparently robust subjects. Diabetics 
are frequent subjects; gout and uraemia have been con- 
sidered as predisposing causes. The frequent location of 
the disease about the shoulders and on the back of the 
neck suggests pressure as a determining cause. Micro- 
organisms are the exciting cause of the disease, the sta- 
phylococcus pyogenes aureus, albus, or citreus, being 
constantly found in the tissues of a carbuncle. 

Pathology. To Warren, 1 of Boston, we owe one of 
the most thorough studies of the pathology of carbuncle. 
He declares it to be a spreading phlegmonous inflamma- 
tion of the subcutaneous cellular tissue. The inflamma- 
tory cells cluster in and about the colunmse adiposse and 
push out laterally from them, infiltrating the skin. They 
reach the surface by mounting up along the hair follicles 
and arrectores pilorum muscles. 

Diagnosis. Carbuncle differs from furuncle in being 
single ; in its brawny base ; in its greater painfullness and 
constitutional disturbance ; in its flatter shape and larger 
size, and especially in its opening at many points and pre- 
senting a cribriform surface rather than a central core and 

i Boston Med. and Surg. Journ., 1881, civ., 5. 



CARBUNCLE. 139 



a crater-shaped opening. Its circumscribed shape, its 
lancinating pain, and its multiple sieve-like openings 
distinguish it from diffuse phlegmonous inflammation 
of the skin. Anthrax becomes gangrenous earlier than 
carbuncle and its centre sinks in instead of becoming 
elevated. 

Treatment. As the disease is an exhausting one the 
patient's strength is to be supported from the start and his 
nutrition kept up by a generous diet. Fresh air b) T good 
ventilation must be secured. If the pain is excessive, 
opium or morphine is indicated, especially to procure 
sleep. Iron is a valuable remedy all the way through, 
and antipyretics should be administered if the fever is 
high. Alcohol should be given if suppuration is free, 
especially if there are any signs of exhaustion. 

The best local treatment in mild cases is the use of car- 
bolic acid, and this gives such good results as to leave little 
to be desired. The crucial incision formerly practised is 
now considered by many modern authorities as harmful, 
though it certainly gives relief for the time by removing 
tension. In like manner the old-time method of poultic- 
ing is condemned, though it, too, contributes to the comfort 
of the sufferer. If the comfort of heat is desired it may 
be obtained by hot fomentations with boric acid. For 
ordinary carbuncles the most efficient treatment is to inject 
them at several points with a 5 or 10 per cent, solu- 
tion of carbolic acid in olive oil or glycerin, by means of 
an ordinary hypodermic syringe. T\ nen there are already 
sloughing points it is well to push into each of them a 
little absorbent cotton wound on the end of a wooden 
toothpick and dipped in carbolic acid, either pure or in 
1 to 4 solution. These procedures are painful for a 
moment, but the pain soon ceases. Hyde and Mont- 
gomery suggest the application of cupping glasses to draw 
out the pus after the carbuncles are open. The mass 
must then be covered with lint soaked in a weak solution 
of carbolic acid or in a saturated boric acid solution used 
hot. It is possible to abort some carbuncles by touching 



140 DISEASES OF THE SKIN. 

them with pure carbolic acid. E. O. Ashe 1 reports the 
cure of one case by the injection of antistreptococcic 
serum. The use of opsonins, Wright's method, is along 
the same line. Eade 2 says that it is possible to abort 
cases in the papular stage by continuous soaking with a 
solution of a mild antiseptic, such as boric or salicylic acid. 

Canquoin's paste and a solution of chloride of zinc, 
1 to 50, have been recommended for use in the same way 
as the carbolic acid. 

Extensive carbuncles are to be treated on surgical 
principles by incision or erosion with a curette. The 
resulting raw surface, as well as that of ordinary carbun- 
cles, is .to be dressed antiseptically with iodoform, iodol, 
or aristol in powder. 

Carcinoma. Epithelioma is the form of cancer that 
most frequently is met with in the skin. It will be 
described under its proper heading. Carcinoma of the 
scirrhous variety rarely attacks the skin. When it does 
it may be primary or secondary. Most commonly it is 
secondary to the same disease of the breast or internal 
organs. It may follow extirpation of the primary deposit, 
and then is prone to begin in the scar. Two varieties 
are described, namely : Carcinoma lenticulare and Car- 
cinoma tuberosum. 

Carcinoma Lenticulare generally appears on the chest 
in the neighborhood of the breast, and is secondary to a 
mammary cancer, or begins in the scar resulting from a 
previous operation for the removal of a cancer of the 
breast. It appears in the form of smooth, firm, glisten- 
ing, dull, or brownish-red or pinkish nodules raised 
above the surface and discrete at first. In size the 
nodules vary from that of a pea to that of a bean. After 
a time the nodules run together and form a thick, indu- 
rated mass, which may involve so much of the chest as to 
interfere with breathing. This is the cancer en cuirasse 

i Brit. Med. Journ., 1898, ii., 1427 
2 Lancet, May 19, 1888. 



CHAP. 141 

of Velpeau. Now the neighboring lymphatic glands are 
involved and the arm of the same side becomes swollen 
and useless. In a short time the nodules and the mass 
break down and ulcerate, and the patient soon dies of 
exhaustion. 

Carcinoma Tuberosum is still more rare. It may occur 
anywhere, but is most frequently seen upon the face and 
hands. It takes the form of disseminated, flat or elevated, 
round or oval tubercles or nodules, seated deeply in the 
skin and subcutaneous tissues. These are of a dull-red, 
violaceous or brownish-red color, and may grow to the 
size of an egg. They do not tend to coalesce, though 
they may crowd close together. They break down and 
ulcerate, and the patient dies just as in the lenticular 
variety. It usually appears in old people. 

In both forms there may or may not be lancinating 
pains, or there may be simply itching. In both, metas- 
tasis may take place. 

Carcinoma Melanodes is described by most authors as 
a third form of carcinoma, but Robinson, Crocker, and 
Brocq regard it as melanotic sarcoma. It is impossible 
to distinguish them clinically from sarcoma, which see. 

Diagnosis. The diagnosis of carcinoma is not difficult 
when .one is aware that there is such a disease, and knows 
that in a given case there has been, or is, a carcinoma 
elsewhere. The mode of evolution of the lesions, the 
involvement of the lymphatic glands, and the lancinating 
pains, all point toward carcinoma as against a tubercular 
syphilicle, lupus, or leprosy. 

Treatment. The treatment of carcinoma of the skin 
is the same as that of other forms, and is quite as unsat- 
isfactory. The rc-rays should be tried. 

Chair du poule. See Cutis anserina. 
Chalazodermia. See Dermatolysis. 
Chancre. See Syphilis, initial lesion of. 

Chap. Usually a mild form of eczema or dermatitis, 
the affected parts being red, possibly slightly swollen, 



142 DISEASES OF THE SKIN. 

and scaly. There often is superficial cracking of the 
epidermis, and these cracks sometimes bleed. The parts 
feel sore. It is generally due to exposure to cold and 
affects exposed parts, as the backs of the hands and the 
lips. It is predisposed to by a congenital dryness of the 
skin, owing to a deficiency of fat in its secretions. It 
may be caused by the use of strongly alkaline soaps, 
chemicals, and other irritants. Thorough drying of the 
hands after washing and keeping them covered from the 
air will prevent its occurrence on the hands. Rubbing 
into the skin cold cream from time to time during the 
day or at night, or the use of a drachm of glycerin in an 
ounce of rose-water, will prove curative. Avoiding wet- 
ting the lips, and making some greasy protecting appli- 
cation, such as camphor ice, will prevent the lips from 
being affected. 

Charbon. See Carbuncle. 

Cheilitis Exfoliativa. The vermillion border of the 
lower lip is the one most often affected, though the upper 
one may be. The lip is swollen and covered with a yel- 
lowish or brownish crust. If this is pulled off there will 
be exposed a red glazed surface that may bleed. Crack- 
ing of the lips may occur. A seborrhoeal eczema of the 
scalp may be found. The cause is unknown. Its course 
is chronic, the disease lasting for years. The daily appli- 
cation of camphor ice will keep the lips comfortable. 
Stelwagon benefitted one case by using dilute, and later 
pure, lactic acid every six hours for four applications 
and repeating in ten days, an ointment containing ichthyol 
and acetanilid being used in the meantime. 

Cheilitis Glandularis Aposthematosa is a disease of the 
lips, usually the lower one. The lip becomes gradually 
swollen, firm, and rather hard to the touch, and its mo- 
bility is impaired. The mucous glands become swollen 
and can be felt as nodular masses. A turbid muco- 
purulent secretion is poured out at times, and the gland 
ducts are more or less dilated. No pain attends the dis- 



CHLOASMA. 143 

ease, which is exceedingly obstinate to treatment. Black 
wash is recommended in the treatment, together with the 
occasional application of nitrate of silver. 

Cheiro-pompholyx. See Pompholyx. 
Chelis and Cheloide. See Keloid. 
Chilblain. See Dermatitis congelationis. 

Chloasma. Synonyms : (Fr.) Chloasme, Panne hepa- 
tique, Tache hepatique, Chalenr du foie, Masque ; (Ger.) 
Pigmentflecken, Leberfiecken ; (Ital.) Macchie epatiche ; 
(Eng.) Liver spot, moth patch, Mask. 

A pigmentary disease of the skin, characterized by the 
formation of yellowish, brownish, or blackish patches of 
various sizes and shapes. 

Symptoms. In this disease the only alteration of the skin 
is in its color. The disease consists in a deposit of pig- 
ment in the rete mucosum, and occurs in the form of cir- 
cumscribed or diffused patches of yellowish to black cir- 
colo ration. When the color is black it is called melasma, 
or melanoderma. The size of the patches varies greatly 
from a small spot up to a general bronzing of the skin. 

The disease may be primary or secondary, idiopathic 
or symptomatic. The idiopathic forms are most often 
secondary to some irritation. Thus it occurs with or in 
consequence of irritants applied to the skin, such as 
blisters or even sinapisms ; prolonged scratching on 
account of some pruriginous disease, such as prurigo, 
pruritus cutaneus, chronic urticaria, scabies or pediculo- 
sis ; exposure to the sun's rays or high winds, or even to 
heat, as of the furnace in iron workers, and then on 
exposed parts. These all cause more or less hyperemia 
of the skin, and besides the deposit of the pigment there 
is more or less discoloration from the changes taking 
place in the extravasated blood. Allied to these causes 
and acting in the same way is the discoloration of the 
skin of the legs met with about old varicose ulcers and 
sometimes without the ulcers when there are marked 
varicosities. 



144 DISEASES OF THE SKIN. 

The symptomatic form may likewise be primary or sec- 
ondary. It is primary in that most common form of all 
that is known as Chloasma uterinum, or the mask, a form 
of hyperpigmentation of the skin of the face that occurs 
during pregnancy, or with uterine or ovarian irritation, 
and that is not met with after the menopause. It usually 
takes the shape of a diffused brownish, light or dark 
discoloration of the forehead alone, or also about the 
mouth and cheeks. Usually it extends only across the 
forehead and down the temples, and is either a continu- 
ous or interrupted patch with sharply defined borders. 
Sometimes it is macular in character and occurs on the 
eyelids, lips, and chin. Under the same conditions there 
takes place a deepening of the color about the nipples 
and along the linea alba. The darkening of the color 
under the eyes of menstruating women is largely due to 
vascular congestion, and little, if at all, to chloasma. 
After a time in some women true chloasma does occur 
there. 

Primary pigmentation also occurs in certain cachexia?, 
such as Addison's disease, tubercular leprosy in Europeans, 
abdominal tuberculosis, cirrhosis ol the liver, cancer of 
the stomach, malaria, diabetes, exophthalmic goitre, and 
multiple melanotic sarcoma. There is also an earthy 
look to the skin in secondary syphilis, as well as in coo- 
genital syphilis. Primary chloasma is also seen as the 
result of the ingestion of arsenic. Argyria is not a chlo- 
asma, strictly speaking. 

Secondary symptomatic chloasma is seen as the sequela 
of syphiloderma and of lichen ruber planus ; these der- 
matoses disappearing to leave behind them, for a greater 
or less length of time, hyperpigmented spots. It may 
occur after other diseases of the skin, but is usually more 
fugitive. It is also seen in senile atrophy of the skin. 
There is hyperpigmentation about the patches of leuco- 
derma and in scleroderma. There is also a pigmentary 
syphilide met with upon the neck in women. 

Etiology. The cause of chloasma is undetermined in 



CHLOASMA. 145 

most cases. A late theory of the pigmentation following 
exposure to the sun is that it is due to the action of the 
chemical rays of the sun upon the constituents of the 
blood. AYe know also that in some cases of hyperpig- 
meutation the color is due to changes taking place in the 
coloring matter of the extravasated blood. That there is 
a relation between chloasma uterinum and the uterus we 
know, because the chloasma usually clears away either 
after parturition, the cure of the uterine disorder, or the 
attainment of" the menopause. 

Diagnosis. The diagnosis is usually easy. Discolor- 
ed ions caused by artificial means can be washed off. 
Chromophytosis is scaly and can be scraped off with the 
nail. Chromidrosis is very rare and can be washed off 
with chloroform or ether. 

Treatment. The treatment of chloasma is very un- 
satisfactory. In many of the symptomatic cases removal 
of the cause will be followed by disappearance of the color. 
Our first duty is to try to find the cause and, if possible, 
remove it. AVhile it is possible to remove the color, it is 
very prone to return. Glacial acetic acid touched on in 
spots will reduce the color and sometimes remove it. The 
same may be said of other acids, care being used not to 
cause too great a destruction of the skin by the stronger 
ones. The bichloride of mercury in 1 to 2 per cent, 
solution may be used for the purpose, applied repeatedly 
or else kept on continuously for three or four hours. 
This causes vesication. The vesicle cover being removed 
the raw surface is to be dressed with a dusting-powder. 
It is not always a safe procedure. Salicylic acid, 10 to 
15 per cent., in ointment, paste, or plaster, or in sat- 
urated solution in alcohol, may do well. Pure carbolic 
acid applied with a swab made of absorbent cotton on 
a small sharpened stick is one of the best applications. 
It turns the skin white, and in a few days the shriveled 
epidermis falls. Unna has recommended washing the 
part with alcohol and applying over night a mercurial 
planter made with the amnion iate of mercury. The next 



146 • DISEASES OF THE SKIN. 

day this is to be removed and the following ointment is 
to be applied : 

R Bismuthisubnit.,| aa £jss; aa 7| 

Kaolini, J 

Vaselini, g^j ad ^jss ; 30 1 M. 

Brocq advises a mercurial plaster during the night, 
bathing morning and evening with a 3 or 5 per cent, 
solution of bichloride of mercury, and wearing during 
the day oxide of zinc or bismuth ointment. 

The peroxide of hydrogen will cause a temporary dis- 
appearance of the pigmentation. Electrolysis may be 
used in small patches. In all cases in which there is an 
underlying cause attention must be given first to it. 

Prognosis. Many of the symptomatic pigmentations 
disappear when the patient recovers his health. It is not 
well to promise a certain disappearance of the patches, as 
some of them are permanent. 

Chorionitis. See Scleroderma. 

Chromidrosis. Synonyms : Ephidrosis tincta ; Stear- 
rhoea or Seborrhoea nigricans ; Pityriasis nigricans ; (Fr.) 
Cyanopathie cutanee, Melastearhee. 

This is a condition in which the sweat has an abnor- 
mal color. Usually it affects only limited regions, espe- 
cially the lower eyelids. The color is most commonly 
blue or blue black. The subjects are most often hysteri- 
cal women, and many of the cases are feigned. 

Besides the lower eyelids the upper ones may be 
affected. Next in frequency the colored sweat forms on 
some other part of the face, but it may occur on any 
portion of the body. Besides the blue or black color, 
cases of yellow, green, brown, and even rose color have 
been reported. A few men have exhibited the phenom- 
enon. Hoffmann 1 reports a case of blue sweat of the 
scrotum of a man seventy-two years old, and White 2 has 

iWien. med. Wochenschr., 1873, xxiii., 291. 
2 Journ. Cutan. and Ven. Dis., 1884, ii., 293, 



CHBOMIDROSIS. 147 

met with a case of yellow sweat iu a man twenty years 
old. R. W. Taylor saw one case of apparently blue 
sweat that occurred in a man taking iodide of potassium, 
and was due to a reaction between the starch of his shirt 
and the iodine contained in the sweat. Constipation and 
nervous derangements are often found in the cases. The 
chromidrosis has been noted to grow worse with increased 
constipation, and become better when that condition was 
removed; to be more pronounced at menstrual periods, 
and to break out suddenly under emotional excitemeut. 
The skin may present no appearance of change except 
the discoloration, or it may have an evident deposit upon 
it. In either case the color can be removed by wiping 
with a little oil, or scraped off partially with the finger- 
nail. Black pigment in the stomach contents, faeces, and 
urine has been noted in some of the cases. 

Etiology. The cause of the disease is obscure. It 
has been thought to be due to the presence of colorless 
indican in the sweat, which becomes blue by oxidation. 
This accounts for a few cases at least. Iodide of potas- 
sium is reported to have colored .the sweat piuk, and 
copper, green. 

Diagnosis. The diagnosis is easy because the discol- 
oration can be readily removed by an oiled cloth, while 
that of chromophytosis does not so readily come oif, and 
that of chloasma does not yield at all. Moreover, 
neither of these last two conditions exhibits a blue colos. 

Treatment. It is important that constipation, men- 
strual disorders, or any derangement of health should be 
relieved. Locally, good results have been reported from 
the use of the following : 1 

R Ac. borici, gr. x ; 2] 

Ac. salicylic!, gr. xv ; 3j 

Ungt. acquae rosae, ad 3J ; ad 100 1 M. 

The red sweat that occurs in the axilla? more especially, 
and elsewhere occasionally, is not a true chromidrosis, 

1 Van Harlingen : Handbook of Skin Diseases. 



148 DISEASES OF THE SKIN. 

but is due to the growth of bacteria [Bacillus prodigiosus) 
upou the hair, as may readily be demonstrated under the 
microscope. The bacteria are sometimes present so 
abundantly as to encrust the hair. The same bacteria 
grown on culture-media are colorless, and it is supposed 
that the action of the sweat upon them determines their 
color. At times not only are the hair and skin stained 
red, but also the underclothing is deeply dyed. 

A mild parasiticide ointment or oil with the use of 
soap and water, or a simple borax solution, will cure the 
disease just as in chromidrosis. 

Gree)b sioeat has been seen in workers in copper and 
those taking the same by the mouth. Yellow sweat has 
been found associated with bacteria and without them. 

Chromophytosis. 1 Synonyms : Pityriasis versicolor ; 
Tinea versicolor ; Chloasma ; Dermatomycosis microspo- 
ria ; Mycosis microsporia ; (Ger.) Kleien Flechte ; 
(Fr.) Pityriasis parasitaire. 

A vegetable parasitic disease, characterized by brown 
or cafe-au-lait colored, variously shaped and sized patches 
that occur chiefly upon the trunk. 

Symptoms. This disease is far more common than 
statistical tables show it to be, as it causes so little trouble 
that many people never think of applying for relief. It 
begins as a small yellowish point, which rapidly grows into 
a split-pea-sized lesion. Many new lesions appear, and, 
these coalescing, patches form which may be so large as 
to occupy a great part of the chest or back. At first, when 
of small size, the patches are circular in shape, but as 
they grow larger they lose all definiteness of shape, 
though their edges are always sharply marked and some- 
times raised. Annular patches sometimes form, and at 
other times there will be many more or less circular 

1 The name of chromophytosis was proposed for this disease by 
Dr. F. P. Foster, and has been well received in New York, as it quite 
accurately defines the disease and brings it in line with trichophy- 
tosis. 



CHR OMOPHYTOSIS. 149 

patches of sound skin in the midst of the diffused patch. 
The color is usually fawn or cafe-au-lait ; it may be 
brown or even black. The latter is reported only from 
tropical countries. In warm weather and in those who 
sweat profusely it is no uncommon thing to see the erup- 
tion present a pinkish hue, due to hyperemia of the skin. 
In negroes the patches are gray or chamois-skin-like in 
color. The edge of the patch may be somewhat raised, 
but the surface is not generally above that of the skin. 
It presents various appearances. At times it is smooth 
and feels greasy ; at times it is dry and covered with 
fine branny scales ; while at times it looks rough, and, 
viewed in the proper light, it presents an appearance 
resembling that of ichthyosis of mild grade. These 
appearances are dependent upon the amount of sweating, 
which, if profuse, will remove the scales, especially if 
the clothing rubs upon the skin. The greasy feel is 
imparted by the oily sebaceous matter, always marked in 
the region of the sternum, where chromophytosis most 
often is located. Whatever may be the apparent condi- 
tion of the surface, scraping with the nail will remove a 
good part of the disease, showing that it is located in the 
upper layers of the epidermis. The patches are located 
chiefly upon the anterior surface of the chest and upon 
the abdomen. The back is also quite often affected, but 
not so markedly as the chest. In very extensive cases 
the arms and legs may show the disease, and a few cases 
have been reported as occurring upon the face. C. W. 
Allen has pointed out that the disease is very often 
found concealed under the pubic hair. The rule is that 
the uncovered parts of the body are spared, and excep- 
tions to this are very rare. The disease is not symmet- 
rical. The number of patches varies from a few to 
hundreds. 

The only subjective symptom is itching, and this is 
often absent, and seldom so bad as to cause the patient to 
seek relief on that account. Patients desire to be treated on 
account of the deformity, not the discomfort, of the disease. 



150 DISEASES OF THE SKIN. 

Etiology. The cause of the disease is the lodgement 
and growth in the corneous layer of the skin of a vege- 
table parasite, the microsporon furfur. Like all other 
parasites of its class, this one is incapable of growth on 
every skin. It flourishes especially upon the skin of one 
who sweats freely. That consumptives were thought to 
be especially prone to the disease is due to the fact that 
their chests are exposed to the physician more often than 
are those of any other class of patients and the patches 
discovered. The disease is contagious, but its contagion 
is of low grade, and it is not common for it to take place 
even in such intimate relations as obtain between husband 
and wife. Adults from twenty to forty years of age are 
the most common subjects, though children may have the 
disease. According to Besnier and Doyon, the disease is 
never seen in very old people. It occurs in all countries, 
but most often in hot climates. It attacks all classes and 
conditions of men, and shows no particular discrimination 
in regard to sex. Its growth is interrupted by malarial 
paroxysms, and it peels off with the desquamation of 
scarlatina and measles. 

Pathology. The microsporon furfur is one of the 
most readily demonstrated of parasites. Place a few 
scales upon the slide, add a drop or two of liquor potassse, 
tease out the material a little, put on the cover-glass, and 
even with a low power the picture presented opposite will 
be seen (Fig. 16). It consists of heaps of conidia, which 
are larger than those of ringworm, with any quantity of 
interlacing mycelia running between them. Free conidia 
are scattered about in the field. The fungus grows in the 
upper layers of the epidermis. It has been asserted that 
there were two kinds of fungus, one brown and the other 
pale red, each of which produces its own colored eruption. 
In 1896 T. Spietschka succeeded in making a pure culture 
of the fungus, inoculating an individual with it, reproduc- 
ing the disease and making pure cultures from it. 

Diagnosis. If one remembers the characteristic feat- 
ures of the disease, yellow or cafe-au-lait, scaly patches, 



CHE OMOPHYTOSIS. 



151 



that can be partly scraped away and are located chiefly 
upon the chest, little difficulty can arise in diagnosis. An 
appeal to the microscope will decide auy doubtful ques- 
tion. Chloasma is not scaly, cannot be scraped off from 
the skin, and does not have spaces of normal colored skin 
in the midst of the patches. Leaeoderma is an absence of 
pigment with a hyperpigmentation about it that comes up 
to the white spot with a concave border and is not scaly. 
A fading erythematous syphilids occurs not in patches, but 
in isolated, round macules that are neither scaly nor 

Fig. 16. 




Micros poron furfur. (After Kaposi.) 

itchy, that are usually most numerous over the abdomen 
and sides of the chest, and that are very often found as a 
disseminated eruption occurring upon the face as well as 
the trunk. Erythvasma is not so scaly and occurs only 
in or about the joints. Its parasite is much smaller than 
that of chromophytosis. 

Treatment. Anything that will'cause the removal of 
the upper layers of the epidermis will cure chromophyto- 



152 DISEASES OF THE SKIN. 

sis when present only in slight degree. But it is best for 
safety to use a parasiticide. One of the pleasantest ways 
of curing the disease is to have the patient scrub his skin 
thoroughly with soap and water, preferably soft-soap, and 
then dab on, twice a day, a saturated solution of hyposul- 
phite of soda. Crocker follows this with a solution of 
tartarac acid 5ij, water Sviij, with the idea of producing 
nascent sulphurous acid on the skin. Sulphurous acid, 
pure or dilute, is a prompt remedy. Vleminckx's solu- 
tion, 1 to 3 or 6 parts of water ; bichloride of mercury, 
2 or 3 grains to the ounce ; sulphur ointment rubbed in 
thoroughly, and tincture of veratrum viride are efficacious. 
The danger of systemic poisoning by either the bichloride 
of mercury or the veratrum viride should deter us from 
using these remedies in extensive cases. Unna 1 recom- 
mends : 

R ^ergf*™ } »*«■ M " 

Brocq gives the following : 

U Acid, salicylici, 2-3 parts. 

Sulphur, praecip.j 10-15 " 

Lanolini, 70 " 

Vaselini, 18 " M. 

Chrysarobin, naphtol, boric acid, and resorcin all are 
good. If the disease is very limited, it can be surely and 
speedily destroyed by painting the spot with tincture of 
iodine. 

There is only one point to be borne in mind in using 
any of these remedies, and that is, that they must be 
thoroughly used and continued for a time even after the 
last trace of the fungus seems to have been removed. If 
one spore is left behind, the disease is liable to return. 
Special care must be given to the cure of the disease in 
the pubic region. The underclothing must be boiled before 
it is used again. Relapses are common, as the patient's 
skin is susceptible to the lodgement of the fungus. 

Clastohrix. See Trichorrhexis nodosa. 

i Vierteljahr. f. Derm u. Syph., 1880, vii., 166. 



CLAVUS. 153 

Clavus. Synonyms: (Fr.) Cor; (Ger.) Leichdorn, 
Hiihnerauge : Corn. 

Symptoms. Corns are circumscribed hyperplasias of 
the corneous layers of the skin due to intermittent pres- 
sure usually from badly fitting shoes, and differing from 
calluses in having a central core that grows down toward 
the corium. They usually occur upon the toes, either 
over prominent joints, where they form hard corns ; or 
between the toes, where, on account of being kept moist, 
they form soft corns. They are usually conical in shape 
and slightly projecting. Unless pared down they become 
painful by being pressed into the cutis. They are some- 
times spontaneously painful on the approach of wet 
weather on account of their being hygroscopic. They 
may suppurate. They may occur upon the palm ; I have 
seen several cases in tennis players. The soles are some- 
times affected with them, and then walking is rendered 
very painful. 

Treatment. The best treatment for corns is to wear 
well-fitting boots and shoes of the straight last pattern, 
which must be neither too large nor too small. Pointed- 
toed shoes are especially apt to cause corns. The corn may 
be removed by the use of a salicylic acid plaster, or by 
Vigier's preparation, now sold under the name of Hebra's 
Corn Remedy, which is composed of — 

R. 



Ac. salicylici, 


gr. xx ; 


1 


5 


Ex. cannabis indicae, 


gr. x; 




75 


Alcoholis, 


n\xx; 


1 


5 


iEtheris, 


Tt\lxxx; 


5 


5 


Collodion flex., 


ad 3SS; 


16 


M. 



which is to be painted on three times a day for a week ; 
then the feet are to be soaked in hot water, and the corn 
picked out. Corns may also be cut out, but the opera- 
tion is at times dangerous, especially in old people. 
They may be pared down and pressure removed from 
them by means of felt rings which come for the purpose. 
J. F. Palmer 1 believes that cutting corns tends to in- 

tClin. Journ., 1906, xxviii., 284. 



154 DISEASES OF THE SKIN. 

crease their size, and advises soaking the feet morning 
and night in warm water, with or without carbonate of 
soda, bread poultices at night, and woollen socks with a 
felt ring over the corn by day. Resorcin plaster of 10 
per cent, strength worn for some days will remove corns. 
Crocker recommends for soft corns careful daily ablution 
with soap and water, painting on them spirits of cam- 
phor at night, and wearing wool between the toes dur- 
ing the day. The ointment of the nitrate of mercury is 
commended for soft corns. Zeisler has cured one case 
with ;r-rays. But unless well-made shoes are worn the 
corns will be sure to return. Corns on the hands may 
be removed with salicylic acid or scraped out with the 
dermal curette. 

Clavus Syphiliticus. Under this title Lewin 1 describes 
certain lesions that he regards as being syphilitic. They 
are horny elevated growths that occur upon the hands and 
feet, and are sometimes surmounted by a delicate scaly 
crown, and sometimes covered with scales. They are 
from pinhead to lentil in size ; circular, oval or oblong in 
shape ; flat or concave on top, but never convex, and 
appear as if wedged into the skin. At first they are pale 
red and soft, but later they become yellowish horn-color 
and hard. They are usually on the palms of the hands, 
but may be on the soles of the feet, as well as upon all 
surfaces of the fingers and toes. There is no pain caused 
by them. There may be some itching. The lesions are 
met with in both sexes, and occur early in the disease, 
and often symmetrically. 

Cnidosis. See Urticaria. 

Cold Sore. See Herpes facialis. 

Colloid Degeneration of the Skin. Synonyms : Colloid 
milium ; (Ger.) Hyalom der Haut; (Fr.) Hyalome cutane. 

Symptoms. This is a very rare disease of the skin 
that occurs most often on the upper part of the face in 

i Arch. f. Dermat. u. Syph., 1893, xxv., 3. 



COMEDO. 155 

the form of disseminated or grouped, discrete, trans- 
parent, shining, rounded, lemon-yellow elevations of the 
skin. Though they look as though they were vesicles, 
they do not contain fluid, and when pricked give exit to 
only a small amount of gelatinous substance and a drop 
or two of blood. They are resistant to the touch. The 
course of the disease is slow. It is capable of spontane- 
ous disappearance by absorption or inflammation, leaving 
an ill-defined mark on the skin. It affects both sexes. 
The youngest patient so far reported was fifteen years old. 
It usually occurs in adult life, and seems in most cases to 
be due to exposure to the weather. It is the result of a 
degeneration of the fibrous elements of the corium. 
There are no subjective symptoms, and the general health 
is good. 

Diagnosis. It differs from xanthoma in its trans- 
parency and in the shining appearance and lemon-yellow 
color of the lesions. In xanthoma the lesions are soft and 
of a dull yellow. In hydrocystoma the lesions are more 
crystalline in appearance, and when pricked a drop of 
pure watery fluid escapes from them. In adenoma seba- 
ceum the lesions are markedly vascular in places. 

Treatment consists in removing them by the curette 
or electrolysis. 

Comedo. Synonyms : Acne punctata, Acne follicularis ; 
(Fr.) Comedon, Acne" punctuee, Tanne; (Ger.).Mitesser, 
Hautwiirmer; Grubs, Fleshworms, Blackheads. 

A comedo is a collection of inspissated sebaceous mat- 
ter retained in a pilo-sebaceous gland, whose mouth is 
closed by a brown or black-topped plug of extraneous 
matter, and appears as a pin-point- to a pinhead-sized, 
slightly elevated, conical papule in the skin. 

Symptoms. Comedones are met with most often upon 
the face, ears, back, and shoulders, and occasionally, but 
much more rarely, on other parts of the body. Wher- 
ever met with they present the characteristics indicated 
in the definition just given. They are unaccompanied by 



156 DISEASES OF THE SKIN. 

inflammatory symptoms. Just as soon as inflammation 
is caused by their presence they are converted into acne 
lesions — a change that they very commonly undergo. 
Usually they are scattered about irregularly ; sometimes 
they are grouped in certain regions. They are single 
lesions in the vast majority of cases, and being pressed 
between the thumb-nails they are readily expressed in the 
form either of an ovoid mass or more commonly as a Ali- 
form or worm-like mass that may be a half-inch or more 
in length, and has a black head that obtains for them the 
popular names of " fleshworms " and " blackheads." 
Very exceptionally they are double, lateral pressure 
squeezing out a filiform mass with a black head at both 
ends, if such an expression is allowable. There may be 
but few, or there may be hundreds of them, so that the 
skin looks as if sown with grains of gunpowder. The 
largest are found in the ears and on the back. They 
give rise to no subjective symptoms. Seborrhoea oleosa 
is frequently a marked complication. 

In children they are more apt to be grouped, and, 
according to Crocker, to appear on the forehead and occi- 
put of boys, the temples in girls, and the cheeks in 
infants. The scalp, too, is in children the seat of the 
disease. Acne may follow them. 

Etiology. All that has been said as to the causes of 
acne applies with equal force to comedones, and need not 
be repeated here. We would only add that Unna 1 does 
not accept the commonly received doctrine that the black 
head and the clogging of the follicle are largely due to 
extraneous matter, but teaches that they are due to the 
corneous layer of the skin being abnormally firm and 
preventing the escape of the follicle contents by growing 
over its mouth. The black color he believes to be anal- 
agous to the coloration of horns in cattle. He calls 
attention to the fact that comedones are more frequent in 
chlorotic girls than in coal-heavers. 

1 Virchow's Archiv., 1880, lxxxii., 175. 



COMEDO. 



157 



It. is quite certain that many cases of comedones are 
directly due to dirt or other foreign matters stopping up 
the follicles. This is supposed to be especially the case 
in children. Colcott Fox l says that in them the come- 
dones are found most often in the spring-time and disap- 

Fig. 17. 



^-x"% 



Demodex folliculorum. (After Kuchenmeister.) 

pear in the winter. The youngest case in a child is one 
at twelve months of age. 2 

Pathology. The pathology of the aifection is the 
same as that of acne without the evidence of inflamma- 
tion. We find many varieties of microorganisms in 
comedones. Sabouraud believes that the microbacillus 
is the cause of comedones. These bacilli form cocoons 
in the mouths of the sebaceous glands and occlude them. 

1 Lancet, 1888, i., 665. 

2 Crocker: Lancet, 1884, i., 704, 



158 DISEASES OF THE SKIN. 

The demodex follieulorum, sl harmless parasite, is very 
often found in the plugs of sebaceous matter. It is long 
and worm-like, with a head, a thorax with four pairs of 
short, conical, three-jointed feet, Avith minute claw-like 
extremities, and a long, tail-like abdomen, which tapers 
off into a blunt and rounded point. (Fig. 17.) 

Von During l has endeavored to show that the double 
comedo is always an acquired formation, and is the result 
of a destructive process between the ducts of two neigh- 
boring glands, so that the two ducts become one, and 
that the destructive process has affected only one gland, 
while the other one is still active enough to produce the 
comedo plug. 

Diagnosis. There is little difficulty in recognizing 

(Fig. 18.) 



^^3> 




Piilard's comedo-extractors 



the disorder. Powder grains in the skin are under the 
skin and cannot be squeezed out. 

Treatment. The same constitutional conditions 
being met with in comedones as in acne, we need not 
repeat here what is said there in regard to their general 
treatment. 

The local treatment consists in pressing out the come- 
dones and stimulating the skin to a more healthy action. 
There is little use in doing the first without the second, 
as the comedo would be sure to re-form. The comedones 
come out most readily after the free use of soap and 
warm water. Then they may be pressed out between 
the thumb-nails, or by means of an old watch-key, whose 

iMonatshefte f. prakt. Dermat., 1888, vii., 401 * 



COMEDO. 159 

sharp edges have been worn down ; or by means of either 
the comedo-presser of Piffard (Fig. 18) or the come- 
do-scoop of Fox (Fig. 19). With some practice they 
may be removed by pressing the back of a small dermal 
curette against one side of the follicle mouth and making 
a quick turn of the end about them. Violent attempts 
at removal should not be made, as they may cause 
inflammation on account of too much irritation. If the 
comedo does not come out readily, wait until another 
time. Stel wagon 1 advises the use of the faradic current 
two or three times a week. Also the daily use of a 
small cupping glass. 

Frictions with green or soft soap and water are excel- 

(Fig. 19.) 



Fox's comedo-scoop. 

lent as a stimulating remedy, care being taken not to set 
up too much reaction. Hardaway recommends : 



R Saponisolivaeprasparat., | ^ -z- - - 25 

Alcoholis, j dJ ' 



M. 



Aquae rosas ad ^vj ; 150 

To be rubbed in with a piece of damped flannel every 
night. He regards the use of sulphur preparations as 
tending to cause comedones, and hence objectionable. 
Alcoholic and astringent lotions of boric acid, alum, or 
zinc are useful. 

Sulphur and most of the preparations given under 
acne are useful. At times the sulphur preparations 
seem to increase the trouble, especially in winter time, 
when there is more or less coal gas in the house from 
stoves and furnaces, and have to be abandoned in favor 
of mercurials. 

The best prophylactic measure is the daily washing of 
the face with soap and water, combined with massage. 

1 Diseases of the Skin, Phila., 1907. 



160 DISEASES OF THE SKIN. 

Condyloma. See Verruca and Syphilis. 
Congelatio. See Dermatitis calorica. 
Corn. Sea Clavus. 

Cornu Cutaneum vel Humanum. Synonyms: (Fr.) 
Corne de la peau ; (Ger.) Hau thorn ; Cutaneous horn. 

This is a rare disease of the skin, in which there 
grows a horn-like excrescence resembling, often in a most 
striking manner, an animal's horn. Horns vary greatly 
as to size. They may attain the length of a foot and a 
diameter of fourteen inches at the base. They are 
usually single, but may be multiple. They may be 
straight, but usually are bent or twisted ; they may be 
laminated, striated, or fibrillated ; they may be yellow- 
ish, dirty-gray, green, brown, or black ; they are solid 
and hard, but not smooth and shining like animals' horns 
often are; and they have rounded or truncated ends. 
They are not painful unless pressed on. When torn or 
knocked off they expose a raw and bleeding surface at 
the base. Sometimes they fall spontaneously or as the 
result of some inflammatory process. Usually they re- 
form. Most of them occur upon the head, nose, face, or 
scalp. They may occur elsewhere, as upon the extremi- 
ties or male genitals. Their base may become the site 
of epithelioma. 

There is little known about their etiology. They may 
occur at any age and in either sex. Most cases occur after 
the fortieth year of life. They seem to be warty growths 
that have undergone corneous transformation. 

Pathology. In the early stages the growth may be 
seen to consist of a group of elongated and hypertrophied 
papillae, upon which the epithelial cells have undergone 
keratosis. At the base of the horn and in the papillae 
are numerous telangiectatic bloodvessels. 

Treatment. The treatment consists in tearing them 
off, under an anaesthetic if large, curetting the base, and 
applying a caustic agent, such as chloride of zinc paste 
or pyrogallic acid. 



CYST, SEBACEOUS. 161 

Couperose. See Rosacea. 

Craw-craw is a disease of uncertain nature, met with 
in the tropics, especially on the west coast of Africa. It 
may be papular, vesicular, or pustular, the lesions being 
disseminated or grouped. Itching accompanies the le- 
sions, and crusts form from the scratching. Ulceration 
sometimes takes place. Both whites and negroes are 
attacked, but chiefly the latter. Several kinds of para- 
sites have been found in connection with the disease, 
especially a species of filaria. 

The treatment consists in the removal of the crusts 
and erasion of the soft tissues beneath, as well as of all 
other lesions, and the application of an antiparasitic. 

Creeping Eruption. See Hyponomoderma. 
Crusta Lactea. See Eczema capitis. 

Cutis Anserina, or Goose-flesJi, is that condition of the 
skin in which, on account of the action of cold causing a 
contraction of the arrectores pilorum muscles and eleva- 
tion of the hair follicles, it feels rough and looks as if 
studded over with minute papules. It is a fugitive 
affair, therein differing from keratosis pilaris, which, 
though resembling it, is constant. 

Cutis Pendula. See Dermatolysis. 
Cutis Tensa Chronica. See Scleroderma. 
Cutis Unctuosa. See Seborrhoea. 

Cyst, Dermoid. These are usually single lesions, and 
look like fibromas. But when they are opened they give 
exit to sebaceous-looking matter. Hair and teeth are 
frequently found in them. They are supposed to be re- 
mains of foetal structures. If single, they can be ex- 
cised. 

Cyst, Sebaceous. Synonvms : Atheroma ; Steatoma ; 
Wen. 

These innocuous little tumors may occur anywhere on 
the body, but are most common on the scalp, face, neck, 
11 



162 DISEASES OF THE SKIN. 

and back. They vary in size from that of a millet-seed 
to that of an orange. They may be rounded, flattened, 
or hemispherical. There will be found in many of them 
a small opening, out of which some of their contents may 
be pressed. The skiu over them may be of normal 
color, pale on account of pressure, or red if the cyst be- 
comes inflamed. They may be elastic and doughy to 
the touch, or firm, or soft, according to the condition of 
their contents, which may be fluid and honey-like, or 

Fig. 20. 



m 



t 




Sebaceous cysts of scalp. (Hyde.) 

cheesy. They tend to grow slowly, and give no trouble 
except by the deformity they cause. In exceptional 
cases they may become inflamed and ulcerate. The hair 
is usually absent over them when they occur on the scalp. 

Etiology. Most cysts are due to distention of a se- 
baceous gland. They occur in both sexes in adult life, 
being rare in children. The origin of dermoid cysts is 
undetermined. Indeed, considerable uncertainty sur- 
rounds the pathology of all of them. 

Diagnosis. They must be distinguished from fatty 
tumors and gummata. Fatty tumors are firmer and more 



DEBMATALGIA, ' 163 

doughy thau cysts, and are more often tabulated, occur but 
seldom on the scalp, and are rarely multiple. Gummata 
are more rapid in their growth, are attached to the skin, 
and tend to break down and ulcerate. 

Treatment. The tumor is to be opened by a linear 
incision, and the contents emptied out, especial care being 
taken to remove the lining membrane of the sac entire. 

Cysticercus Cellulosse Cutis. At times the larvae of the 
tapeworm become lodged in the subcutaneous tissues and 
produce movable, painless, round or oval, pea- or cherry- 
sized tumors, with the skin raised over them. They are 
smooth, firm, and elastic. The larger ones may feel like 
wens. After about eight months (Cobbold) the animals 
die, and the tumors shrivel up and become hard nodules, 
or they may be absorbed. They simulate gummas, lipo- 
mas, sarcomas, carcinomas, and sebaceous cysts. In a 
doubtful case excision or puncture of one of the tumors 
will show under the microscope either one of the larvae 
curled up in its shell, as it were, or the hooklets in the 
fluid that escapes. 

Dandriff or Dandruff. See Dermatitis seborrhoica. 
Darier's Disease. See Keratosis follicularis. 

Dartre Farineuse, Furfuracea, or Volante, Old terms 
for Pityriasis and Eczema. 

Darte Rongeante. See Lupus vulgaris. 
Defluvium Capillorum. See Alopecia. 
Defcedatio Unguium. See Nails, degeneration of. 
Delhi Boil. See Aleppo boil. 

Dermatalgia. Synonyms : (Fr.) Dermalgie ; (Gcr.) 
Hautschmerz, Hautnervenschmerz ; Neuralgia or rheu- 
matism of the skin. 

By this term is meant spontaneous pain in the skin, 
without any appreciable alteration of the same. The pain 
is variously described by patients as boring, pricking, or 
burning ; or numbness or coldness may be complained of. 
It is constant or intermittent in character and some- 



164 DISEASES OF THE SKIN. 

times so severe as to be agonizing. It is generally 
sharply located in a certain region, but may be general. 
The hairy parts are those most often affected, as the scalp. 
The legs and back, and palms and soles are not infre- 
quently involved, as may be any part. Hyperesthesia 
or anaesthesia may be present at the same time. Deep 
pressure may or may not relieve it. It disappears of 
itself after weeks or months. 

Causalgla is one form of dermatalgia. The patient 
complains of a burning pain, and of tenderness, and the 
area supplied by the affected nerve may have a glossy 
appearance. 

Etiology. It is a neurosis that may be idiopathic or 
symptomatic. The idiopathic form is rare, and its 
etiology obscure. The symptomatic form occurs in dys- 
pepsia, locomotor ataxia, rheumatism, syphilis, malaria, 
diabetes, hysteria, chlorosis, and after zoster. According 
to Hyde, it may be a sign of the approaching menopause. 
The majority of its subjects are women. 

Diagnosis. Dermatalgia differs from neuralgia in 
being more superficial and in being accompanied by 
hyperesthesia. It differs from hyperesthesia in being a 
spontaneous pain, while the latter is pain only upon con- 
tact. 

Treatment. If we can remove the underlying cause, 
we shall cure the trouble, so our remedies should first be 
addressed to it. In any case the patient demands some- 
thing to relieve the pain. In the way of internal reme- 
dies we can use salicylate of sodium, quinine, antipyrine, 
phenacetine, some form of opium, hyoscyamus, valerian, 
and other like drugs. Externally relief may be obtained 
by galvanism, blistering, a mustard leaf over the centre 
from which emanates the nerve (Crocker), hot or cold 
water in a rubber water-bag, either alone or alternately ; 
rubbing in Squibb 1 s oleate of morphine, menthol pencil, 
chloroform liniment, tincture of aconite, and the like. 
Galvanism and the high frequency current may be 
tried. 



DERMATITIS BLAST0MYC0T1CA. 165 

Dermatitis Blastomycotica. Under the name of pseudo- 
lupus or blastomycetic dermatitis, T. C. Gilehrist and W. 
R. Stokes 1 described a disease that had been recognized 
for a long time and regarded as a lupus, or at least a 
scrofuloderm. Since the publication of their observations 
cases of the disease have been reported by dermatologists 
of the United States and Europe. J. N. Hyde 2 has 
made the most thorough studies of the affection, and on 
his writings this account is founded. 

Symptoms. The disease usually begins as a split-pea 
sized round papule which may change into a pustule. 
New lesions crop up peripherally and run together so as 
to form a patch ; or the original lesion slowly enlarges so 
as to form a patch. The patch is elevated from one- 
eighth to three-eighths of an inch ; the surface is covered 
by irregular papilliform elevations separated by fissures 
of varying depths, giving it a verrucous or cauliflower 
appearance. In young patches and near the border of 
old ones the papillary projections are fine and the surface 
fairly firm, dry, and wart-like. Untreated areas are 
covered by more or less bulky crusts, which on removal 
expose a papillary surface bathed with a sero-purulent 
secretion. Some of these patches are very vascular and 
bleed easily. Exceptionally we find ordinary unhealthy 
ulcers with exuberant granulations. The papillomatous 
surface may be replaced partly with an elevated scar-like 
surface, pinkish white, irregular, smooth, and shining. 

One of the most characteristic features of the disease is 
the border of the patch. It slopes more or less abruptly 
toward the normal skin, and is sharply defined, smooth, 
dark red or purple, from one-eighth to three-eighths of 
an inch wide, and strewn over with a large number of 
minute abscesses. These may be superficial or deep, and 
when punctured give exit to a small amount of thick, 

1 Johns Hopkins Hosp. Rep., 1897, viii., 46, and Journ. Cutan. and 
Gen.-Urin. Dis., 1897, xv., 393. 

2 Diseases of the Skin, Philadelphia, 1GO0. 



166 



DISEASES OF THE SKIN. 



glairy mucus or muco-pus. Abscesses of the same char- 
acter are found elsewhere ou the patch. 

The course of the disease is chronic. It takes several 
months for a patch to attain the diameter of an inch. It 
may remain stationary for a long time, but usually 
extends slowly and continuously. In course of time new 



Fig. 21. 





V 



Fig. 22. 






Budding organism in tissue. X1200. Hanging drop. X1200. 

Blastomycosis of the skin (Hyde and Montgomery). 1 

patches crop up in the vicinity of the original patch or 
elsewhere. Patches may be as large as the palm or 
larger. Healing takes place in the centre of the patch 
by a flattening of the papillary projections, a lessening of 
the secretion, and the assumption of a verrucous appear- 
ance. Eventually it cicatrizes, producing a smooth, soft, 
inconspicuous scar. A recrudescence of the disease in 
the scar at times occurs. 

The disease occurs most often on the exposed parts, the 
face, neck, hand, wrist, and lower extremities. Some of the 



Courtesy of Drs. Hyde and Montgomery. 



DERMATITIS BLASTOMYCOTICA. 167 

patients remain in fair health, some die of tuberculosis, 
and some from systemic infection by the blastomycetes. 

Etiology. Invasion of the skin by the yeast fungus 
is the cause of the disease. The majority of the patients 
are men, and most are of middle age. J. B. Kessler 1 
has reported a case in a child five months old. Tuber- 
culosis was present in some of the patients. 

Pathology. There are many miliary abscesses, in 
most of which the fungus is found. There are also 
hypertrophy of the epithelial layer of the skin, a large 
number of polymorphonuclear leucocytes, and giant cells 
resembling those found in tuberculosis. 

The parasites are found most frequently in the pus 
from the miliary abscesses. They have a capsule, a trans- 
parent zone, a central protoplasmic mass, and a vacuole 
within the protoplasm. The organism multiplies by 
budding, the buds being of all sizes, several often start- 
ing from the mother body at the same time. 

Diagnosis. From tuberculosis verrucosa blastomy- 
cetic dermatitis differs in its more rapid course, its wider 
spread, and the halo about it being less violet in color. 
But an appeal to the microscope is the only reliable 
means of diagnosis. 

Treatment. The iodide of potassium in large doses, 
from 200 to 500 grains a day, exerts a remarkably ame- 
liorating influence on the disease, but radical destruction 
of the patch by the curette or its ablation by the knife is 
the most reliable curative agent. The .r-rays have seemed 
to help some cases when used in conjunction with iodide 
of potassium. 

The prognosis is bad if blastomycotic septicaemia sets 
in. Otherwise a cure should result if the disease is sub- 
jected to treatment early in its course. 

Belonging to the family of blastomycetes we have 
dermatitis eoccidioides, or coccidioidal granidoma which 
is thought by D. "W. Montgomery and others to be distinct 

Journ. Amer. Med. Assn., 1907 ^xlix., 550. 



168 DISEASES OF THE SKIN. 

from it. It is said that it is almost uniformly fatal, and 
may be purely constitutional without skin lesions. The 
lesions are papules that become circular tumors, covered 
with crusts. In removing the crusts pus escapes, and 
a shallow ulcer is uncovered, having an uneven floor and 
bleeding easily. These increase in size and depth. The 
mold fungus is not found in the tissues in a budding 
state. 

Dermatitis Bullosa, See Epidermolysis. 

Dermatitis Calorica is the inflammation of the skin pro- 
duced by heat or cold, and divides itself naturally into 
two divisions, viz., D. ambustionis and D. congelationis. 
Dermatitis ambustionis is the effect of heat upon the 
skin, the source of the same being either natural, as from 
the sun, or artificial. According to the intensity and pro- 
longed action of the heat and the resistance of the skin 
will be the damage inflicted on the skin. A slight degree 
of heat gives rise to a passing erythema. Burns are due 
to a great amount of heat, and are described for conven- 
ience as being of three degrees. In the first degree the 
skin is reddened, hot, and somewhat swollen ; in the 
second the damage is greater and vesicles and bullae are 
formed ; and in the third, there is complete destruction 
of the skin followed by gangrene. There is always 
considerable pain with any burn, and, if of great ex- 
tent, rise of temperature and shock. Extensive burns 
may be dangerous to life even if not of very high degree, 
and burns involving one-half the cutaneous surface are 
generally fatal. The cause of death in such cases is un- 
certain. One theory, as put forth by Lustgarten, 1 is 
that it is due to a toxin developed by the lodgement of 
microorganisms of putrefaction upon the eschar, proba- 
bly a ptomaine similar to muscarin. Some of the other 
theories are nerve-shock, ulcerations of digestive tract, 
nephritis, decomposition of the red blood-globules ; but 
no one of these is satisfactory in all cases. 

i Med. Rec, 1891, xl., 152. 



DERMATITIS CALOBICA. 169 

Treatment. The treatment of severe burns com- 
monly falls into the hands of the surgeon. In simple 
burns the pain may be relieved by painting them with a 
5 to 10 per cent, solution of cocaine, and then apply- 
ing Carron oil, consisting of equal parts of linseed oil 
and lime-water, to which may be added 5 per cent, of 
carbolic acid, absorbent cotton being soaked with the oil 
laid over the burn and covered with impermeable rubber 
tissue. This forms an admirable dressing that may be 
left on for several days, if care is taken to disinfect the 
part thoroughly before applying it. If this is not 
at hand, the part should be dusted thickly with flour or 
cornstarch until it is procured. Or the burns may be 
covered with a varnish of linseed oil and wax, contain- 
ing 5 per cent, of salicylic acid. Or they may be 
powdered with bicarbonate of sodium or any of the anti- 
septic powders. Or the bullae and vesicles may be 
opened and the surface painted with g 2 to 5 per 
cent, solution of picric acid. The excess of fluid is to 
be drained off and the surface covered with rubber tissue 
or soft gauze that is to be left on for two or three days. 
Deep and extensive burns must be treated on surgical 
and strictly antiseptic principles. Lustgarten, in the 
paper referred to, recommends the administration of 
atropine as a physiological antagonist to the ptomaine, 
the removal of necrotic portions of skin, and dressing the 
wound with carbonate of magnesium, 1 part, and oleum 
rusci, 2 parts. All cases of any magnitude demand 
absolute rest in bed. The continuous water-bath of 
Hebra is excellent where it can be had. 

In sunburn the application of cold cream and a dust- 
ing powder or calamine lotion is usually sufficient. As 
a preventative the skin may be anointed with the grease 
paint used by actors, preferably one of brown color. A 
calamine lotion, used freely, is one of the most efficient 
and agreeable agents for preventing sunburn. 

Dermatitis congelationis, or "frostbite/' is the action of 
cold upon the skin. Like heat, cold produces varying 



170 DISEASES OF THE SKIN. 

degrees of damage to the skin ; if not very intense, the 
effect is an erythema — " erythema pernio," " chilblain " 
— which is passing. These are seen upon the hands, 
feet and face as bluish or purplish-red, circumscribed 
patches, which are cool to the touch, but are accom- 
panied by a feeling of heat, smarting, or burning, both 
while forming and when the parts again become warmed. 
To those predisposed to chilblains, dampness accompanied 
by only very moderately cool temperature is sufficient to 
produce them. Hutchinson speaks of the chilblain 
diathesis to indicate the condition found in these people. 
Their circulation is poor, and they are anaemic. Greater 
degrees of cold at first cause the parts to look white, 
dead, and wrinkled. When the cold is lessened redness 
and swelling supervene. Longer exposure may produce 
bullae and vesicles, or gangrene, either on account of pro- 
longed anaemia or inflammatory reaction from too sudden 
warming. Fingers, toes, nose, or ears may be lost in 
consequence, mortification setting in. Death may result 
from septicaemia. 

Treatment. The best preventive treatment of chil- 
blains is the wearing of woollen coverings on the affected 
parts, and endeavoring to improve the general health of 
the patient and to quicken his circulation. To the latter 
end we may use warm foot-baths, containing salt, at 
night, followed by frictions with alcohol. Whitfield 
recommends giving opium in small doses, or nitroglycerin 
¥¥0" g r * t« i- d. He advocates the use of weak galvanic 
currents, placing the negative pole at the nape of the 
neck and the positive pole in a basin of warm water, in 
which the hands are placed ; if the feet are affected they 
are to be put in the water and the negative pole at the 
lumbar region. A. current of 5 m.a. is to be used for 
ten minutes. When they occur stimulation is necessary, 
for which we may use iodine, either in tincture or oint- 
ment ; ichthyol, 20 to 50 per cent, in water or equal parts 
of camphor and belladonna liniment ; or — 



DERM ATI IIS EPIDEMIC A. 171 



R OLcajuputi , _- 5ij g. 

Liq. amnion, fort., ) 
Sapo. liniment, co., ad ^iij ; ad 100 



M. 



or simple frictions. Care should be taken in severe frost- 
bites not to allow the parts to become warm too rapidly, 
and nothing is better than rubbing them with snow while 
the patient is kept in a cool room. When sloughing or 
ulceration is begun it must be treated on surgical prin- 
ciples. 

Dermatitis Contusiformis. See Erythema nodosum. 

Dermatitis Epidemica. Under this name Savill 1 has 
reported the occurrence, in Paddington Infirmary, of a 
number of cases of an apparently contagious disease of the 
skin, that began either as a discrete papular eruption, or 
as erythematous blotches like erythema nodosum or papil- 
losum, or as small, flat papules enlarging at the periphery 
and spreading like ringworm. This stage lasted three to 
eight days. It was followed by the second stage, which 
was one of exudation or desquamation, and lasted three 
to eight weeks. However the disease began, the lesions 
soon ran together and formed a crimson surface of thick- 
ened and indurated skin, continually shedding its cuticle 
in scales or flakes of various sizes, sometimes mingled with 
drier exudation. In the second stage it assumed either a 
moist type, like eczema madidans, or a dry one like pity- 
riasis rubra. About two- thirds of the cases were of the 
moist variety, and almost all at some period showed slight 
moisture, either in the flexures of the joints or behind the 
ears. Continuous exfoliation was present in all the cases. 
The third stage was one of subsidence. By degrees the 
inflammation lessened, leaving an indurated, thickened 
skin, with polished brown appearance, which was some- 
times raw, or parchment-like, smooth and shining, or 
cracked, or purpuric, especially in aged people. 

The disease began most often in the skin-folds of the 
face and upper extremities ; and involved either the whole 

1 Brit. Journ. Dermat., 1892, iv., 35. 



172 DISEASES OF THE SKIN. 

body or limited areas. It generally spread by continuity. 
The hair and nails were all shed. 

The constitutional symptoms were anorexia and pros- 
tration. There was either no change in the body-tem- 
perature or a slight rise in the evening during the height 
of the disease. Itching and burning were marked, and 
there was considerable suffering experienced in those 
cases in which the epidermis was shed. Relapses were 
freque"^ Albuminuria was found in half of the cases, 
and death occurred in about 12.8 per cent, of the cases. 

More men than women were attacked, and advanced age 
predisposed to it. A specific microorganism is thought 
to have been found in it. 

Clinically these cases resemble dermatitis exfoliativa, 
an instance of the contagion of which I have met with. 
Its proper place has not been determined as yet. 

The treatment of the disease was by antiparasitic 
remedies, but was not very satisfactory. 

Dermatitis Exfoliativa. Synonyms : Pityriasis rubra 
(Devergie and Hebra) ; Eczema foliaceum seu exfoliati- 
vum ; (Fr.) Dermatite exfoliatrice ou exfoliative general- 
ised, Herpetide exfoliative, Erythrodermie exfoliante. 

An inflammatory disease of the skin involving the 
whole cutaneous surface, and characterized by redness, 
dryness, and abundant desquamation. 

The terms dermatitis exfoliativa and pityriasis rubra 
are used interchangeably by most authorities of the pres- 
ent time. If one reads the description of pityriasis rubra, 
as given by Hebra, and of dermatitis exfoliativa, as given 
by Wilson, he will find that the chief difference between 
them is in prognosis, the first being spoken of as uni- 
formly fatal, and the second as tending to recovery in 
many instances. Further, there are not a few cases of 
general exfoliating dermatitis that follow psoriasis, eczema, 
pemphigus foliaceus, and lichen ruber, that present symp- 
toms identical with those of dermatitis exfoliativa with- 
out antecedent disease. It seems justifiable, therefore, to 



DERMATITIS EXFOLIATIVA. 173 

divide dermatitis exfoliativa into two varieties, namely, a 
primary and secondary. 

1. Primary dermatitis exfoliativa or Pityriasis rubra 
of Hebra. 

Symptoms. This disease begins as one or more ery- 
thematous patches in the folds of the joints, upon the 
upper part of the chest, or elsewhere, and these patches 
gradually enlarge. At the same time new patches de- 
velop, and, increasing in size, join the original ones. In 
this way the whole surface may become red within three 
days, or a month or more may elapse before the whole 
surface is implicated. The palms and soles may be un- 
affected for days or weeks. The skin is dry and of a 
bright red at first, without thickening and infiltration, the 
redness lessening and leaving a yellow stain on pressure. 
In a few days, say from six to twelve, scaling begins and 
the skin becomes of a darker red; it may even become 
violaceous. The scales may be large, thin, grayish, at- 
tached at their upper border and loose elsewhere, being 
turned up at their edges. They may be small and adher- 
ent in the centre. The amount of scaling is so great 
that handfuls of scales may be gathered from the bed 
after a night's rest. After a few weeks the epidermis 
may be raised and shed from the hands and soles in the 
form of a continuous sheet, sometimes forming a complete 
cast of the part and leaving a red, dry, glazed surface. 
There is a marked enlargement of the glands in the groin, 
so that the whole packet of glands stands out prominently 
against the red skin. The disease is chronic and the 
scaling constant, though marked with exacerbations. After 
lasting some time there is a certain amount of infiltration 
of the skin, and it seems to grow too small for the body 
and looks stretched and shiny in places. Thus are pro- 
duced ectropion and a puckered condition of the mouth. 
We may also find cracking about the joints and moisture 
in these regions. Furuncles, bullae, or pustules may 
complicate matters. The hair may be shed from all parts 
and the nails become raised from their beds and shed. 



174 DISEASES OF THE SKIN. 

The mucous membranes participate in the disturbance, the 
tongue becomes markedly red, the lips cracked, and the 
nasal secretions are increased. With the ectropion there 
is conjunctivitis. 

The disease begins in some cases with a chill, followed 
by a fever that may rise to 104° F. Fever is present in 
all cases during the early period, and may continue 
throughout. It is sometimes continuous, with evening 
exacerbations; at other times it is only at night. Diar- 
rhea often is met with, and there may be vomiting, 
albuminuria, and pulmonary congestion. The patient 
complains of a feeling of chilliness and of pain, tender- 
ness, stinging, burning, or tingling of the skin. There 
is usually no itching. The sensibility of the skin is 
preserved and the secretion of sweat may be normal, or 
lessened, or increased. The duration is very variable. 
Recovery may take place in six months or a year, or the 
course may be chronic, the patient dying either in a few 
months or after years, by a gradual marasmus, though 
the end is usually hastened by pulmonary complications. 

Cases of localized dermatitis exfoliativa have been 
reported but they are rare. The tendency is for the 
disease to become general, though it may take years to 
do so. Cases of a recurrent type have been met with. 

Etiology. We know very little about the causes of 
the disease. It is a disease of adults, and is more com- 
mon in men than in women. It may occur in children. 
It has been thought to be predisposed to by alcoholism, 
gout, and rheumatism. An attempt has been made to 
trace a relationship between it and general tuberculosis. 
There may be a history of scaling skin diseases in the 
family. Crocker inclines to the belief that a bacillus or 
its toxin will be found as the cause of the disease. At 
present we cannot speak with any certainty as to its 
etiology. 

2. Secondary dermatitis exfoliativa. A condition of 
the skin exactly resembling the primary form is seen from 
time to time to follow upon or develop from a psoriasis, 



DERMATITIS EXFOLIATIVA. lib 

eczema, pemphigus foliaceus, and lichen ruber. I have 
seen one case follow lichen planus. The too vigorous use 
of chrysarobin has been known to be followed by it. 
These cases differ from the primary form only in their 
antecedent skin disease. Once developed they run the 
same course as the primary form, either becoming well 
quickly or falling into a chronic state from which recovery 
may or may not take place. The prognosis is, however, 
much better in the secondary than in the primary form, 
recovery after two or three months being frequent. 

Crocker states that the disease may occur in children, 
though it is very rare. In them it runs a more acute 
course and is attended by severe constitutional symptoms. 
It is usually of the secondary variety. 

Pathology. Histological examination shows that the 
disease is a dermatitis, quite superficial at first, but when 
it has lasted some time the whole depth of the skin is 
involved and eventually there is new connective-tissue 
formation, which subsequently undergoes cicatricial con- 
traction, with abundant pigmentation, hyperplasia of the 
elastic fibre bundles, and obliteration of the skin append- 
ages. (Crocker.) 

Diagnosis. When the features of the disease, as laid 
down in the definition, are remembered, there should be 
no difficulty in recognizing it. No other disease involves 
the whole surface in a uniform dry and scaling redness. 
It differs from psoriasis in being universal, in an entire 
absence of thick, silvery-white scales, and in leaving a 
smooth red surface when its papery scales are removed. 
Should it be secondary to a psoriasis, there will be no 
difficulty in obtaining a history of that disease. It differs 
from eczema in being a dry disease, with little infiltration, 
in its large papery scales, and in itching but slightly. 
Eczema may be almost universal, but some places are apt 
to be spared ; there is always moisture of a sticky sort 
present somewhere or a history of the same ; its scales are 
small and its itching intense. It differs from pemphigus 
foliaceus in an absence of flaccid bulla?. It differs from 



176 DISEASES OF THE SKIN. 

lichen ruber in an entire absence of papules and in the 
whole course of the disease. All these diseases may be 
general, but it is exceedingly rare for them to become uni- 
versal, and it is always possible to obtain a history of their 
having been present at some time in a case of secondary 
dermatitis exfoliativa. It is hardly likely that scarlatina 
could be confounded with dermatitis. A few days' watch- 
ing would in any event decide the question. 

Treatment. The results of treatment of this disease 
leave much to be desired. Many internal and external 
remedies have been tried, but they all are of very uncer- 
tain value. There is no doubt that the patient is most 
comfortable when the skin is well oiled, and vaseline of 
good quality or pure olive oil answers well for this purpose. 
The general health is to be watched over, iron and quinine 
administered, and care exercised to preserve the strength 
by judicious feeding without stimulation. Diuretics may 
be given with the idea of relieving the congestion of the 
skin. Carbolic acid has been recommended, but in my 
hands proved worse than useless in one case. Pilocarpine, 
or jaborandi, is recommended by Hardaway in acute cases. 
Arsenic should not be given till late in the disease, if 
at all. Crocker recommends enveloping the body in 
calamine lotion, and giving bicarbonate of potassium 
every four hours in 20-grain doses, with 12 grains of 
citric acid and 3 to 5 grains of quinine, the whole taken 
while effervescing ; and the giving of quinine in acute 
febrile cases. Sherwell has reported several cases cured 
by the continuous use of linseed oil, both internally and 
externally. The patient is to chew or take in milk sev- 
eral ounces of flaxseed in twenty-four hours. He is to 
be kept in bed with a rubber sheet under him, and to be 
saturated, as it were, in crude linseed oil. If the oil is 
not used abundantly, it is worse than useless. This plan 
of treatment worked admirably in one of my cases. Thy- 
roid extract has proved helpful in some cases. In one 
of mine it aggravated the disease, and the patient made 
a good recovery after it was stopped, and she was treated 
with vaseline, soda baths, and careful feeding. 



DERMATITIS FACTITIA. Ill 

In the primary form, or pityriasis rubra, treatment 
usually only alleviates the sufferings of the patient, but 
does not cure the disease. 

Prognosis. In those cases secondary to psoriasis, 
eczema, etc., the prognosis is good, but should be guarded. 
In the primary cases the outlook is very grave, the mor- 
tality being high. 

Dermatitis Exfoliativa Neonatorum is a disease of new- 
born children, first described by Hitter von Rittershain 1 
and said by him to be quite often seen in the foundling 
asylums of Prague. 

Symptoms. It begins most often at the mouth as an 
erythema, and thence spreads to the trunk and extremities. 
Then the epidermis raises itself from the cutis, rumples, 
and spontaneously exfoliates in large folds leaving a dry 
skin, or there may be exudation under the epidermis. It 
may originate anywhere on the skin. It begins usually 
between the second and fifth week of life, and lasts seven 
or eight days Its course may be prolonged by relapses. 
There is no fever nor digestive disturbances. Furuncles, 
abscesses, or phlegmonous infiltration, with gangrenous 
destruction, may follow. Recovery takes place in about 
half the cases. It is supposed to be a pysemic condition 
of the skin and probably contagious. 

Treatment. Special attention must be given to the 
nourishment of the child, and the maintenance of its body 
temperature. Alkaline lotions will prove beneficial in 
the early stage. Later, a protecting ointment, such as 
that of oxide of zinc, or simple vaseline, followed by 
cornstarch, will be indicated. 

Dermatitis Factitia. It is a good rule to consider the 
possibility of malingering whenever we meet with an 
eruption that does not correspond to any type eruption, 
and at the same time is not due to the action of drugs 
known to have been ingested or locally applied, nor to 
irritants that have come accidentally in contact with the 

1 Arch. f. Kinderheikunde, 1880, i., 53. 
12 



178 DISEASES OF THE SKIN. 

skin. Eruptions are feigned mainly by three classes of 
individuals, namely, soldiers, sailors, or convicts for the 
purpose of shirking work; paupers for the purpose of 
gaining admission to hospitals; and hysterical young 
women for the purpose, of exciting sympathy. Not only 
are feigned eruptions peculiar in appearance, but also it 
will be observed that they are usually on the left side of 
the body, as they are commonly due to acids applied by 
the right hand ; or on the legs. The back is seldom the 
seat of these lesions. Most commonly they are irritative 
lesions, such as would be due to tartar emetic ointment, 
croton oil, nitric acid, carbolic acid, mustard, and the like. 
If made by acids, the lesions will often have lines radi- 
ating from the main mass showing where the acid has 
run further than intended. Some of the lesions imitate 
genuine disease with amazing faithfulness. 

It is impossible here to give a full account of the feigned 
eruptions. A good list is given by Yan Harlingen, 1 and 
to this I would refer the reader. Sycosis by tartar emetic 
ointment and tar ; favus by means of acids ; alopecia are- 
ate by means of plucking the hair ; ringworm by means 
of depilatories; scabies by means of excoriating with a 
fine needle ; various forms of ulcers and pustular eruptions 
by means of acids and caustics ; gangrene in the same 
way ; all these and others have been simulated. In case 
of a suspected feigned eruption the part should be covered 
with an impermeable dressing, when, of course, the lesions 
will soon be well. 

Dermatitis Gangrenosa or Sphaceloderma. Gangrene 
of the skin may be due to a great variety of causes. Many 
cases are due to purely local causes, such as burns, bruises, 
compression, chemical action, and the like. It is seen in 
the course of diabetes, albuminuria, and some cardiac dis- 
eases ; with degenerative changes taking place in the vas- 
cular walls of arteries, or plugging of their lumen ; and 

1 Morrow's System of Gen.-Urin-Dis., Sypk., and Dermat. , vol. iii. 
New York, 1894. 



DERMATITIS GANGRENOSA, 179 

in connection with other skin diseases, as carbuncle. Be- 
sides these we have a group of little-understood cases of 
gangrene, due, apparently, to nervous influences, and occur- 
ring in connection with diseases of the nervous system. 
These may occur anywhere, and may be superficial or 
deep. They behave like surgical gangrene, and are to 
be treated on the same principles. Other cases have been 
reported as following upon some slight injury, such as run- 
ning a needle into a finger. The lesions run up the arm 
or leg in the form of papules that soon change into flaccid 
vesicles, which rapidly crust and form an eschar. When 
the crust falls a depressed cicatrix is left. The process 
tends to last a long time with many relapses. It is always 
to be borne in mind that gangrene occurring in hysterical 
women is apt to be self-imposed. If such cases are care- 
fully noted, it will be observed that the spots appear 
where they can be reached most readily by the patient's 
right hand, or left if she be left-handed. 

Treatment. In all these forms of gangrene attention 
must be given to general health of the patient and the 
lesions must be treated on general antiseptic principles. 

There are two forms of cutaneous gangrene that have 
received special names that must be noticed here. They 
are : 1. Symmetrical gangrene, or Raynaud's- disease ; 
and, 2. Dermatitis gangrenosa infantum. 

1. Symmetrical gangrene. This was first described by 
Maurice Raynaud, 1 and since then has been observed by 
others, although it is a very rare disease. It most often 
attacks the second and third phalanges of the fingers and 
toes, riext most frequently the nose and ears ; but any part 
may be affected. The parts become pale or blue and 
hard, and then swell. They feel numb, but the patient 
may experience darting or stabbing pains in them. If 
pricked, no blood escapes. The process may stop here 
and the parts may return to their normal state ; or after 
a time, hours or weeks, they become black, a line of 

i These de Paris. 1872, 



180 DISEASES OF THE SKIN. 

demarcation forms, and separation of the affected part 
takes place. The process may stop short of the complete 
destruction of the part and recovery may take place, 
though relapses are liable to occur. It may result simply 
in a peculiar induration and thinning of the fingers. 
The disease is symmetrical. It may involve all four 
extremities, but usually only two are affected. Bullae 
may form. The nails may fall. Occurring on other 
parts of the body localized patches show the same symp- 
toms as those on the hands and feet. 

Etiology. Men are more often affected than women. 
People of all ages are liable to it. Exposure to cold 
seems to be a causative factor, and not a few of its victims 
have been subject to chilblains or other symptoms of poor 
circulation. The malarial, the syphilitic, and other cach- 
exise, and the gouty habit have been supposed to be pre- 
disposing causes. It has followed various dermatoses. 
It is probably of neurotic origiD, and due to a contraction 
of the arterioles. 

Treatment. The internal treatment that has done 
best has been the administration of quinine and bella- 
donna. Amyl nitrite and nitroglycerin may be tried. 
Locally, galvanism may be tried, as it has done good. 
Stimulation by means of lotions of various kinds may be 
tried Cold applications are said to be better than hot. 
If gangrene has occurred it must be treated on surgical 
principles. 

Prognosis. The outlook is not good. Death may re- 
sult in those who are not robust. Even if one attack is 
recovered from, another is apt to occur. 

2. Dermatitis gangrenosa infantum (Crocker). Syno- 
nyms : Varicella gangrenosa (Hutchinson) ; Pemphigus 
grangrsenosus (Stokes) ; Rupia eschariotica (Fagge) ; Ec- 
thyma infantile gangreneux (Pineau) ; Gangrenes multi- 
ples cachectiques de la peau ; Ecthyma terebrant de 
l'enfance (Baudouin). 

Under these names has been described a disease of the 
skin that occurs most often after varicella, but may occur 



DERMATITIS GANGRENOSA. 181 

after other diseases of the skin in children, such as variola, 
vaccinia, purpura, erythema nodosum. It consists essen- 
tially in the formation of deep or superficial round or oval 
ulcerations beneath a black slough, following upon a vari- 
cella or other pustule. The lesion when fully formed 
may be one inch or more in diameter, and three-quarters 
of an inch deep. The wider the slough, the deeper is the 
ulcer. Around the slough is a red areola. Crocker says 
that if the gangrene occurs while varicella is still present, 
it begins on the head or upper part of the body, and then 
looks like a vaccination pustule ; while if it begins late in 
the course of the disease, the lesions will be located on the 
lower half of the body, especially the buttocks and thighs. 
In the latter case the affected parts are riddled with ulcers 
of all sizes, shapes, and depths. If several ulcers run 
together, very large and irregular ones may form. If the 
lesions are extensive or numerous, they may cause death 
very frequently by pulmonary complications. 

Etiology. Infants and young children under three 
years of age are those affected by this disease, and most 
of them are girls. Debilitating diseases, such as congen- 
ital syphilis, tuberculosis, and scrofula so called, predis- 
pose to the disease. In my service at the Infants' 
Hospital on Randall's Island cases of this sort were not 
infrequent. In an epidemic of varicella, occurring in 
1890, two cases were met with, one quite extensive upon 
the upper part of the back. The children received in the 
institution are from the lowest dregs of our population, 
and the disease seems to be a product of several dyscrasic 
conditions plus a microbic infection. 

Treatment. The cases are to be managed upon gen- 
eral principles. Tonics, fresh air, good food, and hy- 
gienic surroundings, and remedies addressed as far as may 
be to the underlying constitutional condition are the best 
means for combating the disease. Crocker recommends 
quinine and sulpho-carbolate of sodium, 5 grains every 
three hours, and the injection of 2 or 3 drops of a 2 to 3 
per cent, solution of carbolic acid in several places about 



182 DISEASES OF THE SKIN. 

the patch, and wet boric acid lotions. Locally, my Ran- 
dall's Island cases were treated with iodoform and anti- 
septic dressings. Aristol would probably answer well. 

Prognosis. The prognosis is not good in extensive 
cases. Death is apt to result from lung complications or 
pysemic infection.. 

Dermatitis Herpetiformis. This name was first sugges- 
ted by Duhring, 1 of Philadelphia, for a disease which is 
characterized by great multiformity and marked group- 
ing of the lesions ; by pruritus of varying intensity : by 
chronicity of course : and by a strong tendency to re- 
lapse. Under it he includes the hydroa of Bazin and 
Tilbury Fox, the herpes phlyctsenodes of Gilbert, the 
herpes gestationis of Bulkley, pemphigus pruriginosus 
and circinatus, pemphigus a petites bulle, hydroa bulleux, 
and the herpes circinatus of Wilson. Though the name 
has been adopted generally, the exact status of the disease 
has not been settled. The account of the disease given 
here is based upon Duhring' s writings. 

Symptoms. In severe cases there may be prodromata 
for several days preceding the outbreak, such as malaise, 
constipation, fever, chills, sensations of heat or cold, or 
these alternating, and itching. In mild cases these are 
absent. The onset of the disease may be gradual or sud- 
den — the latter not infrequently. The eruption may be 
diffused over the greater part of the general surface, or it 
may be in localized patches. Favorite sites for it are 
the extensor aspects of the limbs, sacral region, and over 
the scapulae, but the disease has not such marked sites of 
preference as some other diseases exhibit. Itching and 
burning, which are severe, precede or accompany the out- 
break. It may begin as an erythematous, vesicular, bul- 
lous, pustular, or papular eruption, or by a combination of 
two or more of these, the multiformity being a character- 
istic. It shows a tendency for one variety of lesions to 
pass over into another, either during the attack or at 

1 Journ. Amer. Med. Assoc, 1884, iii, 225. 



DERMATITIS HERPETIFORMIS. 



183 



some relapse. Grouping of the lesions is a marked char- 
acteristic of the disease. The relapses occur at intervals 
of weeks or months. AH regions are invaded, the course 
is essentially chronic, and in pronounced old cases the 
skin is excoriated and pigmented. The mucous mem- 
branes may be involved. 

Dermatitis herpetiformis erythematosa. This form is 
usually of urticarial or erythema multiforme type, and 

Fig. 23. 




Dermatitis herpetiformis. 
By the courtesy of Dr. S. D. Hubbard. 

occurs either in patches or diffused. The circumscribed 
patches may coalesce and form larger patches with 
marginate outline. The color varies with the age of the 
lesion, becoming darker with age. There may be maculo- 
papules, flat infiltrations, or vesico-papules. It may con- 
tinue in this way for days or weeks, but usually it 
changes to the multiform type. There is pruritus. 

Dermatitis herpetiformis vesiculosa. This is the form 
most usually met with. The vesicles are from pinhead- 
to pea-sized, flat or raised, irregular or stellate in shape, 
glistening, pale yellow or pearly, firm, tensely distended, 



184 DISEASES OF THE SKIN. 

and without areola. There may be papules, papulo- vesi- 
cles, vesico-pustules, and sometimes bullae. The lesions 
are disseminated, but aggregated into clusters of two, 
three, or more, or may form groups as large as a silver 

Fig. 24. 




Hand of a person affected with dermatitis herpetiformis. (From a 

replica of Baretta's model, No. 1333, in the Museum of the St. 

Louis Hospital, Paris.) 

dollar. If the vesicles are near together, they tend to 
run together and form blebs, which are raised and sur- 
rounded by a pale or distinct red areola, and of a puck- 
ered or drawn-up appearance. The eruption is usually 



DERMATITIS HERPETIFORMIS. 185 

profuse. All regions are affected. Severe itching and 
sometimes burning last until the vesicles are broken, 
which may not be for several days. Sometimes there is 
a good deal of constitutional disturbance. This is T. Fox's 
hydroa herpetiforme. 

Dermatitis herpetiformis bullosa. In this form we have 
more or less typical bullae filled with cloudy or serous 
fluid, from pea- to cherry-sized, irregular or angular in 
outline, and with or without an inflammatory base. They 
occur in groups, with red and puckered skin between, and 
more or less vesicles and pustules, disseminated over the 
skin. All parts of the body are affected. They come 
out in crops at intervals, rupture in two or three days, 
and crust over. This is T. Fox's hydroa bulleux. 

Dermatitis herpetiformis pustulosa. This form is less 
clearly defined than the vesicular form, because vesicles, 
vesico-pustules, and bullae often occur at the same time. 
It may occur uncomplicated and be pustular throughout. 
The pustules are acuminated, round or flat, tense or flaccid, 
and vary in size from a pin-point to a twenty-five-cent 
piece. The large pustules generally have an areola. They 
tend to flatten, spread, and dry in the centre, and to group. 
On the trunk we may find a central pustule surrounded by 
a variable number of small pustules. They are opaque, 
and whitish or yellowish. There may be slight hemor- 
rhagic exudation into them. They are slow of develop- 
ment, an attack lasting from two to four weeks. There 
is more marked constitutional disturbance than in the 
other forms. It is accompanied by heat, pricking, and 
itching. It sometimes precedes, follows, or alternates 
with the other forms. 

Dermatitis herpetiformis papulosa. This is the rarest 
and mildest variety of all, and consists in small or large, 
irregularly shaped, firm, reddish or violaceous papules in 
disseminated groups, the papules being usually excoriated 
on account of the scratching to relieve the severe itching. 
Ill-defined papulo-vesicles are also present. 

Dermatitis herpetiformis multiforme is simply a combina- 



186 DISEASES OF THE SKIN. 

tion of all the preceding varieties, with the type changing 
from time to time. Pigmentation is a feature of this 
variety as well as of all the others, and occurs after the 
disease has lasted for some years. 

Etiology. The disease occurs in both sexes, and is 
supposed to be a tropho-neurosis. It occurs at all ages, 
but most commonly between thirty and sixty years of age. 
My oldest patient was a woman of eighty-two. It has 
been met with in children three and four years of age. 
Little is known as to its causes. It occurs quite indepen- 
dently of pregnancy, and in one case became better during 
the same. Another case was aggravated during preg- 
nancy, and by irregular menstruation. One case seemed 
to arise from a nervous shock. Most cases are seen in the 
subjects of nervous exhaustion of various kinds. By 
Bazin the gouty diathesis was considered to be a predis- 
posing cause of hydroa, and hence possibly of dermatitis 
herpetiformis. Winfield has reported four cases in which 
sugar was found in the urine. Occasionally septicaemia 
may stand in causal relation to the disease. 

Pathology. A careful study of herpetiform hydroa 
has been made by G. T. Elliott. 1 This is considered by 
Duhring as one variety of the disease under consideration. 
He showed that the vesicles originate in the epithelium of 
the sweat ducts, several being implicated at the same time, 
and that the ordinary signs of inflammation are present. 
He believes that the inflammation is secondary, and is 
seated in the papillary layer of the corium. Degenerated 
nerve-fibers are found, and the disease is believed to be due 
to trophic nerve disturbance. Laredde and Perrin 2 are 
of the opinion that eosinophile cells are closely related to 
the process of bullous formation, and that there is a vaso- 
motor paralysis allowing of the escape of bloody or lym- 
phatic serum in the connective tissue and the formation 
of bullae. They raise the question of a possible relation 
between renal action and the escape of eosinophile cells. 

1 New York Med. Journ., 1887, xlv., 449. 

2 Ann. de derm, et de syph., 1895, vi., 281. 



DERMA TITIS HERPETIFORMIS. 187 

T. C. Gilchrist's 1 studies show that iu the early stages the 
vesicles are formed beneath the epidermis on account of an 
inflammatory process going on in the corium. He also 
notes the presence of the eosinophile cells. 

Diagnosis. This disease must be differentiated from 
erythema multiforme, eczema, and pemphigus. It differs 
from erythema multiforme in not occurring markedly upon 
the backs of the hand, wrists, forearms, and feet; in its 
more intense itching, instead of the burning of erythema ; 
in its chronicity and greater tendency to relapse ; and iu 
its obstinacy to treatment. If the case is watched for a 
time, the character of the eruption will be seen to change. 

The vesicular form of dermatitis herpetiformis differs 
from vesicular eczema in having larger vesicles of angular 
or stellate outline, and with no disposition to rupture ; iu 
the grouping of these vesicles in small clusters; in its 
herpetic character; more intense itching; greater consti- 
tutional disturbance ; and greater obstinacy to treatment. 

The papular form differs from papular eczema in the 
irregularity of the size and form of the papules ; their 
strong disposition to group ; their slow evolution ; their 
appearance in crops with free intervals ; the chronicity of 
its course ; and obstinancy to treatment. 

It differs from herpes iris in being a general eruption, 
and in not having the groups of vesicles arranged in 
circles about a ceutral vesicle. 

It differs from -pemphigus in the grouping of its lesious, 
in their more inflammatory, herpetic aspect, and in the 
occurrence of vesicles and pustules at the same time with 
the bullae. If only bulla? are present, the diagnosis is 
difficult. 

Impetigo herpetiformis is always and only pustular, and 
never has erythematous patches, vesicles, or bullae. It 
develops by new lesions springing up in a circular manner 
about the old ones. It is unattended by pruritus, and is 
a grave disease, often ending fatally. 

A well-marked case of dermatitis herpetiformis with 
1 Johns Hopkins Hosp. Rep., vol. i. 



188 DISEASES OF THE SKIN. 

erythematous patches, grouped vesicles, pustules, and 
bullae of stellate form, intensely pruritic and with a 
myriad of excoriations, is so characteristic as to admit of 
no doubt in diagnosis. 

Treatment. This disease is one of the most rebellious 
to treatment. Hygienic measures, fresh air, proper and 
restricted diet, abstinence from all alcoholics, and relief 
from all nervous disturbances must be secured as far as 
may be. Nerve tonics may be given, such as arsenic, 
strychnine, cod-liver oil, hypophosphites, and quinine ; 
alkaline diuretics, belladonna in full doses, laxatives, all 
may be tried. Phenacetine, 5 to 10 grains, three times 
a day, has done well in some cases. Antipyrine exerts 
a more powerful influence, but is not so safe. Locally 
Duhring has found the best treatment to be sulphur oint- 
ment containing two drachms of sulphur to the ounce, 
well rubbed in with vigorous friction as in scabies. In 
one marked case this treatment gave most satisfactory 
results in my hands. The frictions should be continued 
for an hour at a time. This plan is not suitable for the 
erythematous variety. The spinal douche acted most 
favorably in one of my cases. Other authorities recom- 
mend alkaline and bran baths, dusting on starch powder 
with oxide of zinc, Lassar's paste, resorcin ointment, 
liquor carbonis detergens in water, 5ij to Sviij ; calamine 
lotion, liquor picis alkalinus, tar ointment, solutions of 
carbolic acid, 5j to 5j, dabbed on. Guaiacol, 5 per 
cent, in ointment base, controls the itching, The possi- 
bility of systemic poisoning from absorption must be 
borne in mind. Camphor and chloral, 1 to 5 per 
cent., combined in ointment or lotion, also controls the 
itching Schamberg recommends the mercurial vapor 
lamp. All these will afford a certain measure of relief, but 
the disease is apt to laugh at our efforts to drive it away. 

Prognosis. The duration of the disease is indefinite. 
Some mild cases may recover in a short time, never to 
relapse. The course of the disease is essentially chronic ; 
it may last for many years ; it shows a strong tendency to 



DERMATITIS MEDICAMENTOSA. 189 

relapse at longer or shorter intervals ; and, as a rule, does 
not materially affect the patient's health. Old people and 
those not otherwise in good health may be worn out by 
the itching and the discomforts of the disease. 

Dermatitis, Malignant Papillary. See Paget' s disease of 
the nipple. 

Dermatitis Medicamentosa. By this is meant inflamma- 
tion of the skin due to the systemic ingestion of drugs. 
There are a great number of drugs that may cause erup- 
tions upon the skin in susceptible individuals. These 
effects are seen but rarely with some drugs, and quite con- 
stantly with others. The modus operandi of drugs in 
producing eruptions is probably not the same in all cases. 
Some, doubtless, act by irritating the skin while circulat- 
ing in the blood ; some while being excreted by the glan- 
dular apparatus ; while most of them do so by direct or 
reflex excitation of the vasomotor nerves. Idiosyncrasy 
is marked in all of them. Deficient elimination by the 
kidneys is a contributive factor in many cases. Erythema 
is the principal feature of nearly all drug eruptions, to 
which may be added vesiculation or pustulation. Two 
drugs, bromine and iodine, produce pustular eruptions 
in nearly all cases when ingested. Most drug eruptions 
appear with more or less suddenness, and disappear quite 
promptly when the drug is stopped. They are symmet- 
rical and general in distribution as a rule. They may be 
universal or localized, and the extent of the eruption is 
in no way proportioned to the dose. The cause of all 
doubtful eruptions of an erythematous type should always 
be sought for in the ingestion of some drug. As a rule, 
little, if any, treatment is required for this form of der- 
matitis apart from stopping the drug. Sometimes the 
system becomes accustomed to a drug, and after a time 
does not react unfavorably to it if its administration is 
persisted in. With most drugs this is not the case. 

The subject of drug eruptions is so large a one that 
here no more than a skeleton account can be given. 



190 DISEASES OF THE SKIN. 

Acids : Benzoic acid and its compounds may produce an 
eruption of urticaria, maculo-papules, or erythema. Boric 
acid and its compounds may cause an erythematous, psori- 
atic, or erythemato-bullous eruption. The psoriatic form 
is unusual. Carbolic acid causes an erythema that may be 
scarlatinous in character. Nitric acid, in rare cases, gives 
rise to a pustular eruption. Salicylic acid and salicylate of 
sodium produce erythematous, urticarial, vesicular, bul- 
lous, petechial, or purpuric manifestations. Salol has 
produced urticaria. Tannic acid caused an erythema in 
one case. 

Acetanilid causes erythema ; sometimes cyanosis. 

Aconite gives rise to itching, vesicular, pustular, or bul- 
lous lesions. 

Alcohol may cause a generalized erythema and urticaria. 

Amygdala amara causes erythema. 

Antifebrin may give rise to cyanosis. 

Antimony causes an urticarial or vesiculo-pustular erup- 
tion. 

Antipyrin gives rise to an erythema, consisting of small, 
irregularly circular, slightly elevated patches, which may 
be discrete or confluent, and is at times followed by des- 
quamation. Profuse sweating and itching may accompany 
it, and it affects the chest, abdomen, back, and extremities, 
especially their extensor surfaces. It may be measly in 
character or purpuric. It has given rise also to bullous, 
furuncular, and purpuric eruptions ; herpes labialis ; burn- 
ing and necrosis of penis and scrotum. 

Antitoxin quite often causes an urticaria or multiform 
erythema, At times the eruption resembles scarlatina, and 
at other times measles. There are often fever and joint 
pains, and, occasionally, prostration. The eruption may 
not appear until several days after the administration ot 
the toxin, and may last a week or more. 

Argent! nitras when used continuously may produce a 
grayish-black discoloration of the skin, or an erythemato- 
papular eruption. 

Arsenic causes erythema of scarlatinal type, papules, 



DERMATITIS MEDICAMENTOSA. 



191 



petechia?, urticaria, vesicles, pustules, zoster, aud au ery- 
sipelatious eruption. Itching may attend some of these 
eruptions. Grayish or brownish discolorations of the skin 
have followed prolonged ingestion of the drug. Boils and 
carbuncles have also been produced, as well as thickening 
of the skin of the palms and soles, and that over the 
knuckles, either in the form of diffused keratosis or as 
numerous small corns. 




Bromide of potassium eruption in a child 

Belladonna or atropin produces a scarlatinal eruption 
with or without vesicles and pruritus. As the fauces are 
often reddened the resemblance to scarlatina is striking. 
It will clear up in twenty-four hours, and the eruption is 
patchy, not punctate. Moreover, there is none of the 
prodroma of scarlatina nor the strawberry tongue. The 
pupils may be dilated. 

Bromin, in combination with potassium, ammonium, 
and other bases, produces the well-known "bromic acne" 
so commonly seen in the treatment of epilepsy. It is 
an outbreak of dark-red inflammatory papules, papulo- 
pustules, and cutaneous abscesses that bear a close reseni- 



192 DISEASES OF THE SKIN. 

blance to acne, and, like it, often leave scars. It differs 
from acne in having a wider distribution and in occurring 
at all ages. This is the most common form of bromine 
eruption, but erythematous, urticarial, papular, ulcerative, 
verrucose, vesicular, and bullous eruptions have been met 
with. Rarer forms are papillary hypertrophy, resembling 
condylomata, and large, irregular, elevated ulcers. It 
would be desirable to prevent these eruptions, but thus far 
there is nothing that will do so with certainty, except stop- 
ping the administration of the drug. Arsenic, or sulphide 
of calcium, or aromatic spirits of ammonia may be tried. 

Calx suphurata gives rise to vesicles, pustules, and fur- 
uncles ; rarely to petechias. 

Cannabis indica caused a vesicular eruption in one case. 

Cantharides gives rise to erythematous and papular 
lesions. 

Capsicum may cause erythematous and papulo- vesicu- 
lar lesions. 

Chloral produces erythematous, papular, urticarial, ve- 
sicular, and petechial eruptions. At times the chloral 
erythema bears a strong resemblance to scarlatina. 

Chloralamide causes a general punctate hypersemia with 
vesicular lesions with febrile reaction. 

Cinchona and quinine produce all the primary lesions 
of the skin, though most frequently an erythema of scar- 
latinal type, attended by congestion of the fauces and fol- 
lowed by desquamation, 

Condurango causes acne and furuncles. 

Conium causes an erysipelatous eruption as well as an 
erythematous one. 

Copaiba and cubebs. Their most common eruption is 
an erythema which is often of a scarlatinal type, but may 
resemble measles, and may be followed by desquamation. 
Outbreaks of urticaria, vesicles, bullae, or petechia? may 
occur. Pruritus may be present. The odor of the drug 
may usually be detected in the breath. 

Digitalis produces an erythema of an erysipelatous, 
papular, or urticarial character. 



DERMATITIS MEDICAMENTOSA. 193 

Ergot, quite apart from the condition of ergotism, may 
cause vesicles, pustules, furuncles, and petechia. 

Guaiacum and gurjun oil causes eruptions like those of 
copaiba 

Hydrargyrum gives rise to a scarlatiniform eruption, 
followed by desquamation, as well as urticaria, herpes, 
impetigo, purpura, furuncles, and ulcers. 

Hyoscyamus produces an itching erythematous erup- 
tion, with more or less oedema and wheals. Purpura has 
also followed its use. 

Iodine and its compounds, like bromine, give rise to 
a pustular or papulo-pustular, acneiform eruption, usually 
upon the face, back, and upper part of the chest and 
arms ; but often general. This is the most typical form 
of eruption, but an erythema limited to the face and chest 
or general, an urticaria, a vesicular erythema, an ec- 
zema-like eruption, a bullous form resembling pemphigus, 
as well as carbuncular, petechial, and nodular eruptions, 
may occur. Sometimes there will be more than one type 
present. It is supposed that iodic eruptions occur more 
often in cases in which the kidneys are more or less in- 
active. They sometimes follow the administration of 
very small doses. It is thought that the iodide of sodium 
is less apt to cause cutaneous disturbances than are the 
other salts of iodine. At times the system becomes accus- 
tomed to the drug, or the kidneys acting more freely re- 
lieve the skin. The trouble may be relieved or, to a 
large extent, obviated by administering the salt largely 
diluted with vichy or seltzer water, or by giving it in 
milk. The free use of alkaline diuretics will relieve the 
skin. Arsenic has also been recommended, but does no 
better here than in the bromine eruptions. 

Iodoform is sometimes absorbed from surgical dress- 
ings, and gives rise to erythema, urticaria, and purpura. 

Ipecac in one case caused burning heat, with an ery- 
sipelatous eruption. 

Iron is said to produce an acne; also erythematous, 

13 



194 DISEASES OF THE SKIN. 

vesicular, and urticarial eruptions. The iodide of iron is 
the form that usually produces these eruptions. 

Morphin may cause urticaria, ulcers, a papular, vesic- 
ular, or pustular eruption. 

Nux vomica may give rise to a scarlatina-like erythe- 
ma and a miliary eruption. 

Oleum morrhuse may cause an eczematous eruption or 
an acne. 

Oleum ricini may cause an itching erythema. 

Oleum santali may cause a general petechial eruption. 

Opium causes itching and an erythema resembling scar- 
latina or measles in character, which though often widely 
distributed, is not infrequently limited to certain regions. 

Phenacetin may cause a general erythematous eruption. 

Phosphorus causes bullous eruptions, and also purpura. 

Pilocarpin, or Jaborandi, after prolonged use, may 
cause umbilicated papules located in the sweat-glands, 
especially on the face and limbs. These may be topped 
with vesicles or pustules. 

Pix liquida produces an erythema. 

Potassium chlorate has caused a papular erythema, 
while bluish spots on the skin and a general cyanosis 
may occur after continuous use of the drug. 

Quinine produces a scarlatiniform erythema, as well 
as urticarial, purpuric, vesicular, and bullous eruptions. 

Rhubarb may cause a scarlatiniform erythema. 

Salipyrin has caused oedema. 

Salol has caused urticaria. 

Santonin produces an urticaria or a vesicular eruption. 

Stramonium gives rise to an itching or burning scar- 
latinoid erythema, a petechial eruption, or an erysipela- 
toid inflammation. 

Strychnine may cause a scarlatiniform rash. 

Sulphonal produces a scarlatiniform erythema. . 

Sulphur causes dark discoloration of the skin, and an 
eczematous, pustular, furuncular, or papular exanthem. 

Tannin may cause urticaria or erythema. 

Tansy has caused a varioliform eruption. 



DERMATITIS PAPILLARIS CAPILLiTII. 195 

Thallium acetate causes the hair to fall. 

Tuberculin and other serum injections may cause scar- 
latiniform or measles-like patches of erythema, as well as 
a psoriasiform eruption. 

Thiosinamin has caused erythema, swelling of face, 
and redness of fauces and mouth. 

Turpentine and terebene may cause scarlatiniform ery- 
thema and a papular and vesicular eruption. 

Veratria gives rise to an erythematous eruption. 

Veronal has caused erythema, sometimes so profound 
as to be purpuric. 

Beside these, Hyde and Montgomery mention the 
following drugs as having produced eruptions : anacar- 
dium, benzol, chinolin, chloroform, cocaine, creosote, 
duboisin, guarana, kava-kava, lactopheuin, matico, pim- 
pinella, and plumbum. 

Treatment. The treatment of all drug eruptions is 
the same, namely, stopping the use of the drug and giv- 
ing alkaline diuretics. Locally, soothing remedies should 
be applied, such as cold cream, vaseline, and oxide of 
zinc ointment, or preferably alkaline lotions. 

Dermatitis Papillaris Capillitii. Synonyms: Dermatitis 
papillomatosa capillitii ; Framboesia ; Sycosis frambcesia 
(Hebra) ; Sycosis capillitii (Rayer) ; Mycosis framboesi- 
odes, or Acne keloidique, or Pian ruboide (Albert); 
Acne keloid. 

Symptoms. This is one of the rare diseases of the 
skin. It begins as an eruption of small-sized papules 
upon the back of the neck at the margin of the hair. 
They are of the color of the skin, or slightly red with an 
inflammatory halo ; exceedingly hard and firm ; and 
when pricked they give vent to a little bloody serous 
fluid. Increasing slowly in number and crowding to- 
gether, they form raspberry-like elevations with uneven, 
lobulated surfaces. Gradually the disease spreads later- 
ally and also upward upon the hairy scalp, even reach- 
ing the vertex after months and years. After a time the 



196 



DISEASES OF THE SKW. 



masses may soften a little and contain pus. At times 
they secrete a fonl-smelling fluid, and crust. Gradually 
they become sclerosed and keloidal. Pustules may form 
on the hairy scalp, and little tufts of hair protrude out 
of them. When they become keloidal they may be bald 
or tufted with hair. Hairs plucked from the growths 
are sometimes normal and sometimes atrophied. There 
may be pain or tenderness, or there may be no subjec- 
tive symptoms. 

Etiology. Men are more often affected than women. 
The disease may begin at any age. Negroes seem to be more 

Fig. 26. 




Dermatitis capillitii 

subject to it than the white races. They are peculiarly 
prone to keloidal growths, and it is probable that the 
disease is a species of keloid starting in the follicles, such 
as is so frequently seen on the male negro face. The etiol- 
ogy is obscure. It has been suggested that it may be due 
to the rubbing of the shirt collar. 

Diagnosis. If the characteristics of the disease are 
remembered, there should be no difficulty in diagnosis. 
In sycosis we have no hard tumors, and the large hairs 
are surrounded by pustules. Warts are not so hard, do 
not tend to increase in size, and do not become keloidal. 

Treatment. It has been recommended to use sul- 



DERMATITIS BEPENS. 197 

phur preparations in the early stages, and in the latter 
stages to apply a mercurial plaster for one or two weeks, 
alternating it with a 10 or 20 per cent, resorcin or chrys- 
arobin plaster. When the keloidal masses have formed 
they are as rebellious to treatment as keloid usually is. 
Destruction by electrolysis, and the application of the 
high-frequency current, or .r-rays oifer the best prospects 
of success. The latter must be pushed to the production 
of an erythema, and repeated when that subsides. 

Prognosis. So far as reported, the growths are benign 
and have no effect upon the health of the patient. They 
are progressive and show no tendency to spontaneous 
recovery. They are obstinate to treatment and prone to 
relapse. 

Dermatitis Psoriasiformis Nodularis. See Parakeratosis 
variegata. 

Dermatitis Repens. Crocker describes this as a spread- 
ing dermatitis, usually following injuries, and probably 
neuritic in character, commencing almost exclusively on 
the upper extremities. It begins about some slight injury, 
as of the finger-nails, as vesicles or a bulla which, on 
breaking, leave a raw and oozing surface. The border of 
this area is raised up by a clear or turbid exudation, and 
the disease spreads over the affected part with a well- 
defined, undermined advancing edge ; or extension may 
take place by the appearance of new vesicles or bullse just 
beyond the border. Occasionally the disease spreads with- 
out exudation. The character of the eruption suggests a 
parasitic complication, if not cause. The eruption re- 
sembles eczema rubrum by its raw, oozing, reddish sur- 
face, but its sharply defined, undermined, spreading edge 
distinguishes it. In some cases it is papular and in others 
bullous in character. It runs a chronic course, sometimes 
leaves a superficial atrophy on healing, and is obstinate 
to treatment. After removing any loose old skin the 
disease yields best to antiseptics, such as lactate of lead, 
hyposulphite of sodium, permanganate of potassium, sal- 



198 DISEASES OF THE SKIN. 

icylic acid, and white precipitate ointment. In very 
obstinate cases arrays might be nsed. 

Dermatitis from Roentgen Rays. The dermatitis does 
not appear until some days or weeks after the exposure. 
The patient first notices an erythematous patch correspond- 
ing to the point of impact of the rays, attended by swell- 
ing of the skin. This is the mildest form and may soon 
disappear. In most cases the part is painful and the red- 
ness increases in area and assumes a purple hue. The 
pain when present is deep-seated and aching. Pigmen- 
tation of the skin may either precede or follow this form 
of dermatitis. Vesicles and sometimes bulla? form, and 
later the central part of the patch becomes raw, moist, 
and tends to remain for months without healing. Or 
a dry slough may form which, after a time, separates 
and leaves an ulcer, which may not heal for years. A 
keratosis may develop upon the backs of the hands of 
those constantly using the a>rays, and these warty growths 
are liable to become epitheliomatous. A scleroderma- 
tous condition of the hands is also met with. The hair 
and nails may be shed, but they are not permanently lost, 
as a rule. It is not determined what the cause of 'the 
dermatitis is. There is a certain amount of idiosyncracy 
shown in some cases. The placing of lead foil over the 
sound skin, about the part to be operated on, will prevent 
burning. As the cases arise on account of too long 
exposure with a tube placed too near the subject, or too 
frequent exposures, short sittings not too near each other, 
and the greatest possible working distance would seem to 
be the most rational prophylaxis. 

Treatment. In the more superficial burns boric acid 
dressings do well. The deeper burns are very intractable. 
They seem to do best under wet dressings of normal salt 
solution, or diachylon ointment. Pusey commends the 
latter for the keratotic changes of the backs of the hands. 
In some cases the patch has been excised in the hope of 
obtaining a healthy surface. 



DERMATITIS SEBOBRHOICA. 199 

Dermatitis Seborrheica, or Eczema Seborrhoicum. Dr. 
George T. Elliott in Morrow's System of Genito-urinary 
and Skin Diseases, vol. iii., proposed the name of derma- 
titis seborrhoica for the disease, usually called Eczema Se- 
borrhoicum. It is the preferable title. 

Symptoms. Unna teaches that the starting-point of 
almost all cases of seborrheal dermatitis is the scalp; more 
rarely the margin of the eyelids, the axillae, bend of the 
elbows, or cruro-scrotal fold. Upon the head it exists 
mostly as a fine scaling of the scalp that is scarcely notice- 
able at its onset, and it is only after months or years that 
a sudden increase, loss of hair, an unusual amount of scali- 
ness or collection of crusts, severe itching, or, finally, a 
circumscribed moist spot, or an evident eczema, leads the 
patient to consult a physician. The hair during the early 
stage is abnormally dry. A progressive alopecia pityrodes 
may show itself, the scaliness decreasing with the loss of 
the hair to make way for a hyperidrosis oleosa. A 
seborrhoea oleosa may complicate matters, and then we 
find fatty crusts on the scalp. Under these the scalp may 
be pale or slightly reddened. In the majority of cases the 
disease is confined to the scalp. The scaling and crusting 
may increase, a corona seborrhoica may form along the 
hair line, and the affection may extend upon the temples, 
over the ears to the neck, or on the nose and cheeks. 
Or the catarrhal symptoms may be pronounced, and a 
moist eczema affect the scalp and ears, and, in children, 
the cheeks and forehead. (It will be readily recognized 
that the slightest form is the pityriasis of the older 
authorities, the more pronounced form their seborrhoea 
sicca, and the most pronounced form their seborrhoea 
with dermatitis.) 

From the scalp the disease may spread to other parts of 
the body, sometimes proceeding gradually from above 
downward ; sometimes appearing in places far removed 
from the scalp, the interveuing regions being free. Next 
to the head, the sternum is a favorite site for the erup- 
tion, where it most commonly assumes the crusted form, 



200 DISEASES OF THE SKIJS r . 

and most rarely the moist form. The sternum is affected 
secondarily to the scalp. The crusted form is in round or 
oval patches the size of the finger-nail ; these group and 
partly coalesce, forming patches the size of a silver half- 
dollar, having a scalloped border. The color is yellow, 
with a delicate red border. These may clear up some- 
what in the centre and form circles, enclosing a yellowish 
centre ; or break and form bow-shaped figures with the 
convexity outward. The lesions of this form are usually 
covered with a greasy crust. The back is similiarly 
affected. (This is Duhring's seborrhoea corporis.) 

In the axillae we meet most commonly with the moist 
form, and here it shows a tendency to spread with rapidity 
upon the thorax. From the shoulders it spreads down 
upon the arms almost always in the form of yellowish -red, 
crusted papules, which tend to unite in patches, and also 
to form rings. At times it may look very much like 
psoriasis. It shows a predilection for the flexor surfaces. 
The backs of the hands and fingers are often affected with 
a moist eczema, the trunk and arms escaping. 

Upon the palms and soles we find little heaped-up masses 
of scales corresponding to individual coil glands and re- 
sembling psoriasis guttata. Later the epidermis peels off, 
but there is never any moisture. 

The crusted form generally appears in ring or serpigi- 
nous patches on the trunk, buttocks, and hips. The cruro- 
scrotal fold and the approximating surfaces of the thigh 
and scrotum are favorite locations for the disease, proba- 
bly forming here many of the so-called cases of eczema 
marginatum in its dry form with festooned margins to 
the patches, or as an intertrigo when it is more moist. 
The thigh and extensor surface of the knee are but little 
affected, while the popliteal space and the leg often are, 
either in the large papular or the thick-crusted form. 

Upon the bearded portion of the face, when the beard is 
worn, we find either a diffused pityriasis, or circumscribed, 
reddened, itchy patches. Upon the face of women and the 
unbearded portions of the face in men we have circum- 



DERMATITIS SEBORRHOICA. 201 

scribed, scaly, yellowish or yellowish-gray, slightly ele- 
vated patches, mostly on the forehead, cheeks, and naso- 
labial fold. There may also be red papules, free from 
scales or with fine yellow ones, with redness of the skin 
between the papules. The face is the favorite location 
for a moist seborrheal dermatitis in children especially. 
The eyebrows are often involved as well as the eyelids. 
The latter are often swollen, and red, and scaly. The 
vermilion borders of the lips may be affected, and the lips 
swell, scale, crust, and perhaps crack. The disease may 
attack both the outer parts of the ear and the external 
auditory canal. Scaliness, itching, and great iu crease of 
cerumen mark the process in the latter situation. 

Etiology. Seborrheal dermatitis occurs at all ages 
and in both sexes, but it is specially prevalent between 
puberty and thirty years of age. Though most of the 
patients with it seem to be in good health, careful inquiry 
will bring out the fact that they either are not in perfect 
condition or they are living unhygienic lives. Elliot 
thinks that an in-door life favors the disease. It is in all 
probability a parasitic and contagious disease, and its 
spread is favored by neglect of the hygiene of the scalp. 
Barber shops doubtless are distributing centres of the 
malady. It is quite impossible to estimate the prevalence 
of the disease, as only the more pronounced cases are seen 
by the physician. 

Pathology. According to Elliot, it is a dermatitis of 
catarrhal nature. He found evidences of inflammatory 
infiltration about the papillary vessels, and the ascending 
branches from the subpapillary plexus, and along the hair 
follicle, even in what is usually regarded as a pityriasis. 
In seborrhea sicca, so called, the infiltration extended to 
the plexus itself, while in the higher grades the inflam- 
mation involved nearly the entire cutis. The sebaceous 
glands were apparently unchauged, and there were no 
evidences of the incomplete metamorphosis of their cells 
such as is usually described in seborrhea sicca. Con- 
trary to Unna's observations, he never found any fat in 



202 DISEASFS OF TEE SKIN. 

tne sweat glands or their ducts, though there were evi- 
dences of degeneration of the glands ; nor did he find 
fatty infiltration of the cutis or rete. 

Unna has described a mulberry coccus in this disease 
which he names morococcus. Dr. Merrill x has suc- 
ceeded in isolating a diplococcus, in making a pure culture 
of it, and in reproducing the disease by inoculation. If 
his observations are corroborated, we have the evidence 
that the disease is parasitic. Other microorganisms 
have been found by other investigators, and the end is 
not yet. 

Diagnosis. Many cases formerly regarded as eczema 
are now included in seborrheal dermatitis. In diagnosis 
stress is laid upon the fact that the disease begins upon 
the scalp and spreads from there downward in a more or 
less capricious manner ; upon the more or less absence of. 
itching ; upon the superficial character of the lesions, 
their tendency to take on definite forms, their yellowish 
color, and the greasy feeling of the crusts. In all these 
things the disease differs from an eczema. At times 
seborrheal dermatitis of the body bears so striking a 
likeness to pityriasis rosea that is hard to differentiate 
the two. Pityriasis rosea does not occur on the scalp ; 
but as seborrheal dermatitis is of very common occur- 
rence on the scalp, and may be found in conjunction 
with pityriasis rosea, this is not of much aid in diagnosis. 
The rings of pityriasis rosea are not so greasy and yellow, 
have fawn-colored, dry centres, and lack the punctate 
border so often seen in seborrheal dermatitis. The 
papular lesions of pityriasis rosea are not so much raised 
as are those of seborrheal dermatitis and not so evidently 
related to the follicles of the skin. Pityriasis rosea 
commonly runs a rapid and self-limited course, whereas 
seborrheal dermatitis is chronic. If pityriasis rosea 
occurs typically upon the trunk, there is no difficulty ; 
but when scaly ring-shaped patches occur on the limbs 

i New York Med. Journ., 1895, lxii., 528, and 1897, lxv„ 322. 



DERMATITIS SEBORRHOICA. 203 

alone a positive diagnosis cannot be made without a good 
deal of study. 

The psoriasiform seborrheal dermatitis differs from 
psoriasis in occurring in locations not typical of psoriasis, 
and in having a more yellowish cast of color, and more 
greasy, yellowish scales. Many cases can be diagnosti- 
cated only by taking into consideration the probabilities 
for and against psoriasis. 

Treatment. It is necessary to pay special attention 
to the scalp in every case, as that is the place of de- 
parture in almost all cases. In the treatment of the 
disease we have three useful drugs : sulphur, resorcin, 
and mercury. If a patient comes with the dry and scaly 
form of the disease, no matter whether there is or is not 
apparent inflammation, I find the best thing to prescribe 
is sulphur j and the most elegant prescription is 

R 



Sulphur, precipitat., 


3iijss ; 


14. 


Cerae albae, 


Siijss; 


14. 


01. petrolati, 


^ijss; 


78. 


Aquae rosae, 


giss; 


46. 


Sodae biborat., 


gr. xviii; 


1. 



This is known as Sulphur Cream. It is to be applied 
once a day for two or three days. Then the scalp is to 
be washed. After drying, the ointment is to be applied 
and repeated every other day for ten days. After wash- 
ing and drying, the ointment is to be applied three times 
a week, and so the number of applications are to be 
reduced until the ointment is used once or twice a week, 
and the head washed every two or three weeks. The 
efficacy of the ointment is sometimes increased by the 
addition to it of 2 or 3 per cent, of salicylic acid. 

Where there is a good deal of oiliness of the scalp, 
and where the use of an ointment is objected to, this 
prescription may be given : 



R 



Hydrarg. bichlorid., 


gr. i; 




Resorcinol, 


5i; 


4 


01. ricini, 


3ss; 


2 


Alcohol, 


ad giv; 


120 



06 



204 DISEASES OF THE SKIN. 

This is to be applied morning and night by means of a per- 
forated cork, if for a man ; or a medicine dropper, if for 
a woman. Once every few days, if the scalp becomes 
dry, it is well to rub in a little sweet almond oil, or an 
ointment containing 2 or 3 per cent, of resorcin. The 
strength of the resorcin in the prescription must be 
increased from time to time up to, perhaps, 10 per cent. 
Care must be taken not to use resorcin on blond or gray 
hair, as it stains the hair a green color. The lotion may 
cause an exfoliation of the scalp, which does no harm, 
and usually does not recur. 

As a substitute for the sulphur ointment, and in those 
who cannot use sulphur, this prescription will be found 
excellent : 

R Hydrarg. ammon., gr. xx-xl. 5-10 

Hydrarg. chlor. mitis, gr. xl-lxxx ; 10-20 

Vaselin, ad. ^i; ad 100 

This is known as Bronson's Ointment. It is to be used 
in the same way as the sulphur cream. 

Saliey lie, acid, 3 to 5 per cent., in the form of a 
lotion for the scalp, and of an ointment for the body ; 
and the ammoniate of mercury ointment in full strength 
or diluted, are both excellent. Hodara 1 recommends in 
the dry forms of the disease an ointment composed of 

R Chrysarobin., gr. y 50 ad 1% 02-1 

Ichthyol., gr. % B ad 1% 04-1 

Vaselin. , ad 5UJ ; ad 100 M. 

which is to be applied at night and removed with cold 
cream in the morning. If reaction occurs, the ointment 
should not be used until it subsides. On the scalp the 
chrysarobin may be used in the same strength in alcohol, 
with the addition of a little castor oil. At times very 
obstinate patches of psoriasiform seborrheal eczema will 
be met with on the scalp, especially at the margin of the 
hair over the forehead. The best application for these is 
a 10 per cent, solution of chrysarobin in a 50 per cent. 

1 Monatshefte f. prakt. Dermat., 1899, xxix., 264. 



DERMATITIS VENENATA. 205 

aqueous solution of ichthyol. This was first used by 
Dr. C. T. Dade, of New York. 

The prescriptions given for use on the scalp may be 
used for the disease elsewhere on the body, but oint- 
ments are to be preferred to lotions. 

Prognosis. There is practically no permanent cure 
of the disease, because of the multitude of hair follicles 
that are the hosts of the parasite. By constant care of 
the scalp the disease is readily held in check, but when 
the scalp is neglected, a relapse is to be expected. 

Dermatitis Traumatica. This term is used to comprise 
all inflammations of the skin that are due to traumatic in- 
fluences, such as blows, rubbing, and the like. It presents 
the usual signs of inflammation to a greater or less extent, 
even up to gangrene, according to the degree of trauma- 
tism and the susceptibility of the individual skin. The 
irritation of the skin due to scratching is a common 
instance of this form of dermatitis. Under certain cir- 
cumstances it easily develops into an eczema. The 
chafing of the skin met with in horseback riding, in 
those unaccustomed to the exercise, is another common 
instance. 

Treatment. The treatment of this form of dermatitis 
should be soothing, such as by the free use of dusting 
powders, alkaline lotions, or mild ointments, such as that 
of the oxide of zinc. Unna 1 recommends for the preven- 
tion of the dermatitis due to horseback riding, that the 
part should be smeared with a weak resorcin or ichthyol 
ointment. 

Dermatitis Venenata. Redness, swelling, and heat, fol- 
lowed or attended by the formation of a vast number of 
small, closely crowded vesicles that may remain isolated 
or run together and form bullae, are the symptoms that 
constitute this form of dermatitis, the cause of which 
is always some sort of irritant applied to the skin. The 

* Monatshefte f. prakt. Dermat., 1888, No. 21. 



206 



DISEASES OF THE SKIN. 



irritant is usually of a chemical nature, and quite com- 
monly is derived from plants. 

Rhus poisoning. The most frequent cause of derma- 
titis venenata is contact of the susceptible skin with the 
leaves of the rhus toxicodendron, the poison-ivy, and the 



Fig. 27. 




Dermatitis venenata from poison ivy. 1 



rhus venenata, the poison-sumach, and the rhus diversi- 
loba, the poison-oak. Dr. James C. White, 2 of Boston, 
has written a most complete and learned work on the 
subject, and it is to this that the reader is referred for 
a more detailed account of the disease than can be given, 
here. The mildest degree of irritation is an erythema. 

1 Dermatitis Venenata. Boston, 1887. 

2 From a photograph by Dr. H. W. Blanc, of New Orleans. 



DERMATITIS VENENATA. 207 

Commonly the reaction is more marked. The patient 
first experiences a little burning or itching, and attention 
being drawn to the part it is found to be reddened and 
swollen. In some cases we may have wheals. In a few 
hours papules, then vesicles, will form and perhaps bullae. 
The swelling may be intense, so as, on the face, com- 
pletely to close the eyes. I have seen it so great on the 
scrotum as to give the appearance of an immense hydro- 
cele. The vesicles may be present in a countless multi- 
tude. The acute developing symptoms may last several 
days, and then gradually subside. The vesicle contents 
either dry up or discharge upon the skin. The parts crust, 
the swelling and redness slowly disappear, and the skin 
once more becomes normal. The parts most usually 
affected are the hands and face in both sexes, the penis 
in the male and the breast in the female — that is, those 
parts that come in direct contact with the poison, or to 
which it is most liable to be conveyed by the hands. 
In some rare cases, and in extremely sensitive individuals, 
the whole body may be affected, and there may be grave 
constitutional disturbances. These bad cases are met 
with for the most part in children whose legs are uncov- 
ered, and whose resistance to the poison is not great. 
Most persoDS, perhaps, are not susceptible to the poison. 
Some few are so susceptible that even having the wind 
blow on them from over one of the plants will cause the 
dermatitis. Negroes are almost immune. 

It is not true that the dermatitis will relapse after an 
interval of time, but it has been observed that an eczema 
may follow the dermatitis, and that this may show a cer- 
tain amount of periodicity in its outbreaks. White says 
that while the poison may be most active in the flowering 
season, it is sufficiently active in all seasons, and that the 
poison resides not only in the leaves, but also in the wood, 
bark, and fruit. The disease is not contagious after the 
parts have been well washed. 

Pathology. The cause of dermatitis venenata when 
due to ivy or dogwood is toxicodenclric acicl. Accord- 



208 DISEASES OF THE SKIN. 

ing to S. F. Acree and W. A. Syme, 1 it is a poisonous tar, 
gum, or wax, which is non- volatile and a complex sub- 
stance of a glucoside nature. It is easily oxidized by per- 
manganate of potassium ; and precipitated into an insol- 
uble lead compound by acetate of lead. 

Diagnosis. The eruption differs from that of eczema 
in seeking the inner sides of the fingers, the hands, face, 
breast, and genitals ; in the greater amount of swelling 
that commonly attends it ; in the vast number of crowded 
together, " lurid " vesicles ; and in the occasional occur- 
rence of the eruption in the early stage in streaks, sugges- 
tive of striking against the plant. A history of having 
been in the country will sometimes be an aid in diagnosis. 

Erysipelas of the face sometimes needs to be differen- 
tiated. If the hands or genitals are affected at the same 
time with the face, that will decide in favor of dermatitis 
venenata. Besides this, erysipelas almost always is at- 
tended by constitutional disturbances and it spreads with 
a raised border. 

Treatment. A saturated solution of bicarbonate of 
sodium, that can be procured anywhere, will afford relief 
promptly. The parts are to be kept constantly covered 
with lint or absorbent cotton continuously saturated with 
it or with lime-water. At night we cannot use this if 
the patient sleeps, as the cotton or the lint dries. So it 
is better at this time to use some simple ointment, as cold 
cream, oxide of zinc, or diachylon diluted one-half, the 
last being the best. This treatment commends itself on 
account of its efficacy, cheapness, safety, and accessibility. 
Ichthyol in aqueous solution from 10 to 40 per cent, 
strength is highly commended by some. White recom- 
mends black wash (calomel, 5j ; aq. calcis, Oj), applied 
for half an hour at a time, two or three times a day. He 
cautions against the danger of using it in extensive cases. 
As a substitute for it he gives : 

U Zinci oxid., giv; 16 

Ac. carbol., 3J 5 4 

Aq. calcis, ad Oj ; ad 500 M. 

1 Jour. Biolog. Chem., March, 1907. 



DERMATITIS VENENATA. 209 

Sugar of lead in solution is a well-known remedy, and 
is efficacious but dangerous. Morrow 1 recommends : 

R Sodii hyposulphitis, ^j ; 25 1 

Glycerini, Jss ; 12 5 

Aquae, ad ^viij; ad 2001 M. 

Acree and Syme recommends a 1 per cent, aquseous 
solution of permanganate of potassium used as hot as 
can be borne for half an hour. They say the staining 
of the skin can be removed by soap and water. The 
caution against the use of alcohol which tends to spread 
the poison. The following formula may be tried : 

R Zinci oxidi, j" 

Magnesias carbonat., aa^j; 4! . 

Aristol, 3ij ; 8j 

Aquae rosae, ad ^iv; 1201 M. 

It sometimes aborts the disease when used early. 

After the acute stage has passed the case should be 
treated like an eczema. If the constitutional disturbance 
is marked, the patient should be cared for upon general 
medical principles. 

While the poison-oak, or ivy, causes the symptoms 
most often spoken of as dermatitis venenata, there are a 
uumber of other plants that will produce like, if not so 
severe, symptoms. Of the commoner ones we find the 
oleander, Jack-in-pulpit, skunk cabbage, bitter orange, 
May-apple, arnica, burdock, golden rod, and common 
daisy. But space will not allow of a complete list of 
these. Goa powder and its derivative, chrysarobin, pro- 
duce a marked dermatitis in addition to the mahogany- 
staining of the skin. The action of croton oil, mustard, 
stinging-nettle, and oil of turpentine is well known. Tar 
may excite a general dermatitis or an acne-like inflamma- 
tion of the follicles called " tar acne," the follicles of the 
skin being stopped up and their mouths filled with a black 
plug of tar. A somewhat similar eruption is seen in 
workers in flax and paraffin. ^ r orkers in picking and 

1 Journ. Cutan. and Ven. Dis., 1886, iv., p. 180. 
14 



210 DISEASES OF THE SKIN. 

packing peaches may have an eczematous dermatitis de- 
veloped upon the wrists, forearm, neck, and upper part 
of the chest. 

A great number of chemicals produce dermatitis of 
varying degree. Pyrogallic acid produces burning and 
inflammation, and covers the part with a black coating 
on account of its oxidation. Not only does it destroy dis- 
eased tissues, but it may cause also sloughing of the 
sound skin. Chloroform will blister if prevented from 
evaporating. This peculiarity is sometimes employed for 
vesication. The strong acids destroy the skin, as also 
arseuic. Sulphur, iodine, iodoform, creolin, mercurial 
preparations, chloride of zinc, bichromate of potash, and 
caustic potash cause varying degrees of dermatitis. Elec- 
tricity will redden and inflame the skin, and not a few 
cases of dermatitis have resulted from wearing clothing 
dyed with aniline dyes. It is said that the brown tail 
moth coming in contact with the skin will cause an erup- 
tion like dermatitis venenata. Its hairs contain an ir- 
ritant poison. 

Dermatitis Vegetans. Under this, and other names, 
have been reported by Hartzell, Wende, Pusey, and some 
French writers, cases in which pea-size or larger, fungat- 
ing tumors develop, which may run together to form 
patches of more or less large size. The lesions, whether 
large or small, are dark red in color. They exude pus 
and serum, and crusts form on them. They may itch a 
little, but cause no constitutional disturbance. They 
occur both in children and adults, and seem to be due to 
the invasion of purulent ezematous surfaces by staphy- 
lococci. They yield to antiseptic treatment. 

Dermatitis Verrucosa. Occasionally we see cases marked 
by patches which are circumscribed, raised, with their sur- 
faces presenting a markedly uneven, papillomatous or 
warty appearance. There is a narrow zone of redness 
about the patches. A drop or two of serum may ooze 
from them, or thick pus* Pressure upon them will usu- 



DESMOIDES. 211 

ally force out pus. There may be only one patch, or 
several patches. Commonly they will be on the same 
part of the body. The patients are usually in poor phys- 
ical condition. They may be the subjects of other skin 
diseases, such as chronic eczema. They do not complain 
of itching. The disease seems to be due to streptococcic 
or staphylococcic infection, and to yield best to snug 
bandaging with the ammoniate of mercury ointment, or 
salicylic acid ointment ; or to wet dressing of antiseptic 
character. At times the disease is very intracticable. 
It is probably allied to dermatitis vegetans. 

Dermatolysis. Synonyms : Chalazodermia ; Cutis pen- 
dula ; Pachydermatocele. 

This term is applied to two entirely different diseases 
of the skin. In one we have folds of loose, thickened 
skin and subcutaneous tissue that sometimes form huge 
masses hanging down from the side of the face, trunk, or 
any part of the body. The skin is soft, and does not 
appear altered, excepting that it is pigmented to a certain 
extent. This form is really a species of fibroma. True 
dermatolysis is a yet more rare affection, in which, owing 
to some defect in the attachments of the skin, it can be 
pulled away from the body like the skin of a cat. The 
a Elastic-skin Man" is an instance of this. There have 
been several of these freaks. The one mentioned could 
pull the skin from his chest up to his eyes. The condi- 
tion is congenital, but can be increased by cultivation. 
There are no other changes in the skin itself. 

Treatment. The treatment of the first variety is by 
excision before it becomes too large. 

Dermatomycosis Furfuracea. See Chromophytosis. 

Dermatosclerosis. See Scleroderma. 

Dermatosis Kaposi. See Atrophoderma pigmentosum. 

Dermatosis Linearis Neuropathca. See Papilloma lineare. 

Dermographia. See Urticaria factitia. 

Desmoides. See Fibroma. 



212 DISEASES OF THE SKIN. 

Dhobie Itch. According to Stelwagon, who has recently 
gone over the literature, in the tropics, during the warni 
weather the fungi of ringworm, chromophytosis, and 
erythrasma, cause a dermatitis of the axillae, crotch, and 
feet, which is characterized by a more or less pronounced 
festooned border. The patches are very pruritic, and 
when scratched become raw. Boils and abscesses, the 
result of secondary infection, often complicate matters. 
With the advent of the cooler weather, the disease tends 
to recovery, and is well in winter time. 

The Treatment is cleanliness of the patient, and the 
use of antiseptics such as boric acid, salicylic acid, bichlo- 
ride of mercury, and the like. 

Diabetic Eruptions. According to Brocq, they may be 
divided into two great classes: 1. Those in direct rela- 
tion to alterations in the general economy, such as 
pruritus, chronic papular urticaria, acne cachecticorum, 
erythema, lichen, eczema, herpes, ecthyma, furuncle, car- 
buncle, xanthelasma, gangrene. 2. Dermatoses due di- 
rectly to the contact of the secretions of the body charged 
with sugar, and more especially the eczema of the gen- 
itals caused by contact with the urine. 

Kaposi 1 has described a bullo-serpiginous gangrene of 
diabetics which begins as a disseminated eruption of bul- 
lae upon the extremities. The bulla? dry up in the centre 
into a black crust, while at the periphery there is a ring 
of fluid pushing up the epidermis. When the crust is 
removed sphacelated skin is exposed, which separates and 
leaves a red, granulating surface. The penis is a favorite 
site for this form of gangrene. It must be treated on 
general surgical principles. 

Diphtheria of the Skin. A. Schucht 2 states that diph- 
theria of the skin takes the form of ulcers, which at first 
are small and superficial. Later they become confluent, 
large, of irregular shape with scalloped borders running 

i Wien. med. Presse, 1883. 

2 Archiv. Derm. u. Syph., 1907, lxxxv, 105. 



DYSIDROSIS. 213 

out into the sound skin. Their edges are slightly infil- 
trated, intensely red, here and there undermined, but usu- 
ally perpendicular. Their floor is covered with a grayish- 
white, adherent diphtheritic membrane. They have only 
a slight odor. When cleaned they heal rapidly. There 
is slight constitutional disturbance, with temperature not 
high. 

They occur without the presence of diphtheria else- 
where, and are most often seen in the crotch where inter- 
trigo is present. Diphtheria bacilli are found in the ulcers. 
Diagnosis. Hospital gangrene differs from diphtheria 
in having ulcers covered with a dirty grayish-green to 
blackish membrane, many millimetres thick, which is 
gelatinous, pasty, and looks like the result of burning 
Avith an acid. They are surrounded by a bright inflam- 
matory zone, and have a foul odor. High fever, and 
severe constitutional disturbance accompany them. There 
are no diphtheria bacilli present. Ecthyma infantile 
always begins as a pustule, the ulcers formed are more 
superficial, oval, and without diphtheritic membrane. 
I leus molle is crater- form, with undermined edges. It is 
inflammatory, swollen, and without diphtheritic mem- 
brane. 

Distichiasis. This is a congenital or acquired condition 
of the cilia, in which they grow in two distinct rows, the 
inner row being directed inward so as to scrape the cornea. 
According to Michel, generally the outer third of the 
upper lid is affected alone, the deformity is symmetrical 
and bilateral, and of embryonic origin. Electrolysis 
offers the best method of relief. These cases belong to 
the ophthalmic surgeon. 

Dracontiasis. See Guinea-worm disease. 

Drug Eruptions. See Dermatitis medicamentosa. 

Duhring's Disease. See Dermatitis herpetiformis. 

Durillon. See Callositas. 

Dysidrosis. See Pompholyx and hidrocystoma. 



214 DISEASES OF THE SKIN. 

Dystrophie papillaire et pigmentaire. See Acanthosis 
nigricans. 

Ecchymomata and Ecchymoses. See Purpura. 
Ecdermoptosis. See Molluscum epitheliale. 

Ecphyma Globulus is described by H. L. Purdon 1 as 
a contagious disease occurring in Ireland. It begins 
as a tubercle which, after a time, softens and is replaced 
by a raspberry-like tumor. All parts of the body may 
be affected excepting the hands and feet. It is chronic 
in its course, but can be cured by applications of the 
nitrate of silver. 

Ecthyma. Synonyms : Furunculi atonici ; Phlyzacia 
agria; (Ger.) Eiterpusteln ; (Fr.) Puroncles atoniques; 
(Ital.) Rogna grossa. 

A cutaneous eruption of deep-seated pustules, with 
hard, elevated, reddened bases, attended by the formation 
of thick, greenish of dark-colored crusts, and followed 
either by cicatrices or dark pigmented spots. 

Symptoms. As usually described, the disease consists 
in an outbreak of one or more round, flat pustules, whose 
covers are not fully distended, and which have an inflam- 
matory areola. In size they vary from that of a split 
pea to that of a finger nail, or larger. At first they are 
white or yellow. Subsequently they may or may not 
become reddish from the admixture of blood. They may 
dry up, forming a crust, which, on falling, leaves a healthy 
surface. Or they may rupture spontaneously or be broken, 
and form a thick, greenish or blackish crust, under which 
is a raw or superficially ulcerated surface, which on heal- 
ing leaves a pigmented or slightly cicatricial spot. In 
subjects in bad hygienic surroundings quite deep ulcers 
may result. These pustules are usually discrete, but they 
may group. They are both painful and tender. Any 
part of the body may be affected, but they are most often 
seen on the extremities, especially the legs, where the hair 
is coarse, the shoulders and the back. The course of the 

1 Dublin Journ. Med. Sci., 1897, ciii., 486. 



ECTHYMA. 215 

disease may be acute, each pustule lasting five or ten 
days, and the whole disease lasting about two weeks ; but 
generally it is chronic, and kept up by the outbreak of 
fresh crops. There is more or less itching, soreness, and 
pain. It is both contagious and autoinoculable. Febrile 
symptoms may accompany or precede the outbreak of the 
disease, but as a rule they are absent. It is, in all prob- 
ability, only contagious impetigo modified by the char- 
acter of the soil upon which it is planted. 

Etiology. Dirt, want, bad hygienic surroundings, 
the strumous diathesis, or a broken-down, cachectic con- 
dition brought on by intemperance or dissipation, all pre- 
dispose to the disease. It is quite often seen in the genus 
"tramp." It follows, not infrequently, upon scratching 
on account of pediculi and scabies. It is most often seen 
in adults, and is rare in children. Like in all other pur- 
ulent diseases, pus cocci, both staphylococci and strepto- 
cocci, are found in the pus, and are the contagious element 
in the disease which is carried from place to place to pro- 
duce new foci of infection. Sabouraud teaches that it is 
the streptococcus of Fehleisen that is the specific causa- 
tive microoganism, staphylococci being also present sec- 
ondarily. 

Diagnosis. Ecthyma differs from eczema in having 
much larger and deeper pustules, which are discrete and 
not confluent, in the marked areola about the pustules, 
and in the absence of all other signs of eczema. It differs 
from impetigo contagiosa in its pustules being deeper ; in 
their location upon the extremities rather than upon the 
face and hands ; in not having that flabby, bullous look 
of a burn of the second degree, so common to impetigo ; 
in having thick greenish or blackish crusts, and not straw- 
colored stuck-on crusts ; occurring in more or less de- 
bilitated adults and not in otherwise healthy children. 
But all these alleged differences can be readily explained 
away by the difference in the character of the soil on 
which the contagious principle is implanted. Ecthyma- 
tous pustules are often seen in connection with impetigo 



216 DISEASES OF THE SKIN. 

contagiosa. From impetigo it differs principally in its 
being a deeper and more inflammatory process, and in 
occurring in debilitated subjects. It resembles the large, 
Hat, pustular syphlloderm ; but its crusts are not heaped up 
into oyster-shell-like masses, as in syphilis, and when 
they are removed they leave a more superficial, and not 
so punched out an ulcer. There are more pain and itch- 
ing in ecthyma, and an entire absence of other symptoms 
or history of syphilis. It differs from furuncle in having 
no central core, and in not being so deep a lesion nor so 
painful. 

Treatment. The first thing to be done in these 
cases is to obtain cleanliness, proper hygienic surroundings, 
and complete abstinence from alcoholics. If there is a 
general debility, tonics must be given and the dietary 
improved. Locally, all crusts must be removed with 
soap and water, the lesions dressed with an ointment 
containing some antiseptic such as — 

}£ Hydrag. ammon., £) j ; 5 

Ungt. zinci oxidi, 3J ; 100 M. 

and the parts enveloped in a bandage, where such can be 
applied. An ointment or oil containing 10 or 15 grains 
of salicylic acid to the ounce will also answer well. If 
ulcerations have formed, they should be treated as will be 
indicated under Ulcers. 

Ecthyma infantile gangreneux. See Dermatitis gan- 
grenosa infantum. 

Ecthyma terebrant de l'enfance. See Dermatitis gan- 
grenosa infantum. 

© 

Eczema. Synonyms : (Fr.) Dartre vive, ou humide, 
eczema ; (Ger.) Ekzem, Hitzblatterchen, Flechte, nas- 
sende Flechte, Salzfluss ; Salt rheum, Tetter, Humid 
tetter, Scall, Scald, Heat eruption. 

A non-contagious inflammatory disease of the skin, 
sometimes acute, more often chronic, attended with itch- 
ing, desquamation or loss of the cuticle, and usually with 



ECZEMA. 217 

the exudation of serous or sero-puruleut fluid either be- 
neath the cuticle or upon the denuded surfaces. It may 
present erythema, papules, vesicles, or pustules, and its 
lesions show a decided disposition to run together and 
form infiltrated patches. 

Symptoms. This is a most protean disease. It has 
been well said that if a student learns to recognize and 
treat syphilis and eczema, he has possession of the key 
to the whole of dermatology. There are seven promi- 
nent symptoms of the disease : 

1. Redness. 

2. Itching. 

3. Infiltration. 

4. Tendency to moisture. 

5. Crusting or scaling. 

6. Cracking of the skin. 

7. Tendency of the lesions to run together and form 
patches. 

In every case there will be four or five of these symp- 
toms preseut at the same time; or perhaps all of them. 

Eczema begins suddenly, and most often without any 
constitutional disturbance. Should slight fever and ma- 
laise be present, they are accidental, or an expression of 
that condition of the system that predisposes to the dis- 
ease, and not part of the disease itself. Very often the 
first thing that attracts the patient's attention is itching, 
and when he examines the skin he finds it reddened, and 
either scaly or covered with papules, vesicles, or pustules ; 
or moist. 

The tendency of eczema in all forms is to form patches, 
which are infiltrated to a greater or less extent ; ill de- 
fined ; shade off imperceptibly into the surrounding skin, 
so that it is hard to say where they end, with outlying 
lesions about them ; irregular in shape ; of all sizes, some- 
times involving nearly the whole cutaneous surface ; 
sometimes swollen, and of dark-red color ; sometimes 
with a shade of yellow. Beginning by a few lesions, the 
disease increases more or less rapidly in extent, and it is 



218 DISEASES OF THE SKIN. 

by the running together of the individual lesions that 
the patches are formed. It may clear away after a short 
time, or it may last weeks or months, or become chronic, 
showing little tendency to recovery. There is no con- 
stant rule as to the course of the disease, though many 
cases occur and recur at certain seasons of the year ; it 
may be in the summer, spring, autumn, or winter. Any 
or all parts of the skin may be affected, but it has a pre- 
dilection for the flexures of the joints, the face, the scalp, 
and the sulcus behind the ear. There may be but a 
single patch or many patches. It commonly affects both 
sides of the body, but with no marked symmetry. 

The subjective symptoms are itching, burning, and a 
feeling of heat and tension. Of these, the most constant 
is itching, which is present in all cases, and is often so 
great as to cause the patient to excoriate the skin by 
scratching. It is subject to exacerbations and remissions. 
The latter may be complete or incomplete. Burning and 
tension are experienced for the most part only at the be- 
ginning of the attack or during some exacerbation of a 
subacute or chronic case. 

The old definition of the disease was that it is a vesi- 
cular one. It is well to disabuse the mind of this im- 
pression at the start, as there is a form of the disease 
that is dry throughout — the erythematous form. Though 
even here the visicles though unseen, are present deep in 
the skin. There are five forms of eczema, known as the 
erythematous, papular, vesicular, pustular, and squam- 
ous. Eczema madidans is but a convenient term to 
describe a very moist eczema. Eczema rimosum or 
rhagadiforme is but an eczema in which there is crack- 
ing of the skin, especially about the joints. 

Before discussing each of these forms by itself, it is 
necessary to understand that no one of them, excepting 
perhaps eczema erythematosum, is clear cut and unchang- 
ing. On the contrary, the disease may begin as a papu- 
lar erythema ; upon the papules vesicles may form, which 
will run together and soon break down of themselves 



ECZEMA. 219 

and form a weeping patch ; the subsequent lesions may 
then be pustules, and the final stage through which all 
varieties pass before recovery is the squamous. It is 
common to see several varieties at the same time. 

Eczema erythematosum is most often encountered upon 
the face of an adult, though it may occur elsewhere and 
in children. Beginning as one or more ill-defined red 
patches, it soon forms a continuous patch by the coales- 
cence of the smaller ones. Sometimes the whole face is 
involved, sometimes there are several patches. The in- 
flammation is often attended by oedema to such an extent 
that the eyes are nearly closed if the disease is in their 
neighborhood. The patient experiences great discomfort 
on account of the itching and the burning and stiffness of 
the skin. The skin feels harsh, dry, and thickened ; it 
is swollen ; its color is bright or dull red ; there are a 
slight amount of small adherent scales and many small 
excoriations. If it occurs on contiguous folds of the skin, 
there may be moisture. Upou the face vesicles and 
papules may develop, but they are exceptional. After 
lasting for a time the symptoms may subside and re- 
covery take place, the patches fading away altogether 
and not in the centre alone. It may assume a chronic 
form and last for years. It is seen at times upon the 
body in the form of very superficial, pale-red, scaly, 
round, circumscribed patches, and constitutes one form 
of the so-called parasitic eczema. 

Eczema papillosum. This is the lichen simplex of the 
old writers. It consists in an eruption of pin-point to pin- 
head-sized, bright or dull-red, acuminate, discrete, grouped, 
or perhaps confluent papules. They are often in relation 
to the hair follicles. Very frequently the papules are 
capped by vesicles. The papules may remain discreet 
throughout their course, with an occasional small confluent 
patch to betray the nature of the disease. These patches 
are frequently no larger than a silver dollar in size and 
fairly well defined. This is one of the most itchy vari- 
eties of this pruritic disease, and the scratching consequent 



220 DISEASES OF THE SKIN. 

upon it produces excoriations, and, breaking down the 
vesicles and papules, gives exit to the serum and converts 
the patch into a moist one. This variety is located prefer- 
ably on the extensor aspects of the limbs. The life of the 
individual papule is comparatively long — days or weeks. 
It is often obstinate to treatment. 

Eczema vesiculosum is the most common and most char- 
acteristic form, and consists in an eruption of pin-point to 
pinhead-sized, rounded or acuminate vesicles that appear 
upon a reddened surface in immense numbers. Prickling 
and tingling precede the outbreak ; intense itching and 
more or less swelling attend it. The vesicles group, and 
perhaps coalesce, and soon rupture of themselves, and 
discharge a clear, sticky, mucilaginous fluid that possesses 
the quality of stiffening and staining linen, and dries into 
a light-yellow crust. The vesicles rupture so early that 
it is rare for the physician to see a case with the vesicles 
intact. New vesicles form about the patch, and break 
down ; the discharge continues from the sites of the vesi- 
cles, and the crust continuously forms. A raw surface is 
exposed when the crusts are removed. Sometimes when 
the crust is prevented from forming on account of friction, 
there is a weeping surface, which has been called eczema 
madidans or rubrum. Eventually the discharge ceases, 
the hyperemia lessens, scaling takes place, and after a 
time the skin returns to its normal condition. This form 
of eczema seeks the soft parts of the skin, the flexures of 
the joints, the flexor surfaces of the limbs, and behind 
the ears. It may involve the whole or nearly the whole 
cutaneous surface. After it has lasted a little while in a 
part the skin is evidently thickened. With it papules 
and pustules very generally are found. 

Eczema pustidosum. Like the pustular syphilide, this 
form of eczema occurs in more or less broken-down, cachec- 
tic, delicate, or strumous subjects. It is the most com- 
mon form of eczema met with in children, and in them 
occurs by preference on the face and head. The eruption 
consists of small pustules that may start as pustules or 



ECZEMA. 221 

develop from vesicles. They are present in large num- 
bers, and tend to break down and form patches covered 
with greenish crusts. If blood is drawn by scratching, 
the crust will be blackish. They are somewhat larger 
than the characteristic vesicles, and have a fondness for 
hairy parts, though any part of the. body may be affected. 
This and the previous form often merge into each other. 
It may develop from any of the other forms of the disease 
on account of infection by pus cocci. It is not so itchy 
as the other forms. It may change into an eczema 
maclidaus, and it passes through the squamous stage on 
the way to recovery. 

While the above described forms of eczema are in 
some cases fairly well marked, in very many cases several 
forms will be present at the same time. Thus we may 
see erythematous patches here, while there vesicles may 
form which change into pustules, while scattered about 
are numerous papules. 

Eczema squamosum is the final stage through which all 
cases pass on their way to recovery. In it the skin is dry, 
red, and covered with thin, papery, flat, large or small 
scales. It is a condition of the skin in which the forma- 
tion of its corneous layer falls short of perfection. The 
disease may continue in this condition for an indefinite 
time, a chronic eczema with occasional exacerbations. 
Then it may pass away entirely and the skin become quite 
well; or some local injury may cause an acute outbreak of 
eczema. The skin in this form is more or less thickened, 
and deep cracks are liable to form about the joints, because 
the infiltration of the skin interferes with its elasticity, 
and it breaks instead of stretching when the joint is 
extended. While the patches are usually ill defined, in 
some cases they will be round, and with well-marked 
borders. This form is spoken of as orbicular eczema. 

Eczema may be acute, subacute, or chronic — terms that 
apply not to the length of time that the disease has lasted, 
but to the symptoms it presents. In acute eczema there 
are the usual signs of inflammation — heat, redness, and 



222 DISEASES OF THE SKIN. 

swelling. There may be constitutional symptoms of fever, 
chills, prostration, and the like, in this stage. This stage 
is usually of short duration, and passes over into the sub- 
acute stage. Now the swelling lessens or disappears, but 
there is an active evolution of lesions, papules, vesicles, 
or pustules, as the case may be. After a time the chronic 
stage is reached, when the disease takes the form of red- 
dened, infiltrated, scaly patches. It is prone to take on 
acute symptoms under slight irritations. In severe at- 
tacks of eczema the patient may be confined to bed and 
greatly prostrated. In the great majority of cases, while 
the patient suffers much discomfort, he does not feel ill. It 
predisposes to ulceration upon the legs when combined with 
varicose veins, and then is named eczema varicosum. This 
must not be confounded with a somewhat similarly sound- 
ing name, eczema verrucosum, which is a rare form, in 
which the skin takes on a warty appearance on account 
of a hypertrophy of the papillae. 

Etiology. Like its symptoms, its causes are numer- 
ous. It may arise from purely local causes, but even then 
it is probable that we should assume in most cases a pre- 
disposition on the part of the skin. Thus, we have eczema 
of the hands in washerwomen. Perhaps for a score of years 
they had washed in water from the same source and with 
the same kind of soap without eczema. Then under the 
same local conditions, but with some unknown internal con- 
stitutional state, an eczema breaks out. Of external irri- 
tants, we have the sun, water, intense artificial heat, acids, 
alkalies, traumatism, rubbing of apposed surfaces or chaf- 
ing by the clothing, parasites — in fact, just the same things 
as will cause a dermatitis, only now the action goes further, 
and a catarrhal condition of the skin results. Cold has 
an undoubted influence on the skin, and eczema is more 
common in winter than in summer, and is generally aggra- 
vated by extremely low temperature, even when the patient 
keeps in the house. It has been observed that children 
with eczema grow worse when it is cold and a high wind 
is blowing, even though they are not exposed directly 



ECZEMA. 223 

to these conditions. Vaccination may act as a local 
cause. 

Of the internal or predisposing causes, perhaps the 
most common and active is some digestive or intestinal 
disturbance — it may be dyspepsia or malassimilation, or 
derangement of the liver, or constipation. At other 
times the kidneys are at fault. Diabetes and Bright\s 
disease both predispose to eczema. Chlorosis and anemia, 
uterine disorders and the menopause, and the strumous 
diathesis are at times active factors. Derangements of 
the nervous system are exciting causes ; now and again 
we meet with cases which appear suddenly after some 
nervous shock. Rheumatism and gout and varicose veins 
are other predisposing causes. To most of these internal 
causes some external irritation must be added before the 
eczema appears. 

The French school of dermatology has long held to 
its theory of diathesis, and has taught that the dartrous 
diathesis is the cause of eczema. Outside of France little 
is known about diathesis. A vulnerability of the skin 
is necessary for the production of an eczema, and many 
patients may fairly be regarded as eczematous, just as 
others may be spoken of as gouty, or rheumatic, or 
psoriatic. This peculiarity or tendency of the skin may 
be inherited, and in so far eczema may be regarded as 
hereditary. 

The disease occurs in all ages, conditions, races, and 
both sexes, and is the dermatosis we are most often called 
upon to treat. It is especially common in children. In 
Bulkley's tables, out of 3000 cases, 676 occurred under 
five years of age ; and of these, 520 were in children 
under three years. Of the remaining cases, 1234 were 
between the ages of twenty and fifty, and were divided 
about equally in each decade. About one-third of all 
skin diseases are eczema. 

These many etiological factors indicate that it is 
probable that our present eczema is a too composite dis- 
ease, and it is for this reason that attempts are constantly 



224 DISEASES OF THE SKIN. 

made to take away certain members of the family and 
form them into separate diseases. Thus far no micro- 
organism has been demonstrated as the cause of the dis- 
ease, though the pus cocci are found in the pustular form. 
The vesicles of eczema are sterile, which is evidence 
against the disease being parasitic. They are doubtless 
often the cause of pustulation, which may be a matter 
of secondary infection. Unna teaches that there are two 
other varieties of the disease, one due to reflex nervous 
irritation, such as is seen during dentition of infants, 
and one dependent upon the tubercular diathesis. 

Pathology. Eczema is a catarrhal inflammation of 
the skin, analagous to that of the mucous membrane, 
which has its seat principally in the papillary layer of 
the skin and in the rete. This superficial location of the 
disease is the reason why the skin is left unmarked after 
the disease has been recovered from. In chronic eczema 
there is marked cell infiltration of the corium, producing 
the characteristic thickening of the skin. The subcuta- 
neous tissues may be affected by this infiltration. The 
papillae, bloodvessels and lymphatics are considerably 
enlarged. In advanced cases the skin appendages may 
suffer obliteration. The sticky yellow exudate of eczema 
is made up of serum containing in solution or suspension 
the detritus of degenerated rete cells. This secretion 
when dry forms the peculiar gummy yellow glaze or 
crusts. A tropho-neurosis is supposed by many to be 
the cause of the disease when not due to local irritants, 
and Crocker quotes Marcacci as having found chauges 
in the sympathetic in a fatal case of universal eczema. 

Diagnosis. If the six prominent symptoms of eczema 
are remembered, namely, redness, itching, infiltration or 
thickening, exudation or tendency to moisture, crusting or 
scaling, and cracking, it will be a great aid in diagnosis. 
To them should be added the tendency the disease 
evinces to locate in the folds of the joints, between 
apposed surfaces of skin and behind the ears, and the 
peculiar mucilaginous quality of the exudate, which 



ECZEMA. 225 

stiffens and stains linen and glues the hair together. 
Fortunately, a diagnosis of eczema will fit one out of 
every three cases. Here will be given the general diag- 
nosis, reserving for the sections on regional eczema the 
diagnosis of special forms when necessary. 

Dermatitis is often distinguished with difficulty from 
eczema, and frequently passes over into it. As a rule, 
it runs a more rapid course, its vesicles are longer pre- 
served, bullae are apt to form, there is burning rather 
than itching, and it heals readily on removal of the 
cause, which usually is evident. 

Dermatitis exfoliativa is, when fully developed, a uni- 
versal eruption, while eczema is very rarely so. It is 
also dry, and has abundant large scales ; while eczema 
will exhibit moisture somewhere, and does not scale so 
abundantly. For further points in diagnosis, see under 
dermatitis exfoliativa. 

Erysipelas is attended by fever and marked constitu- 
tional disturbances, has a sharply defined border, ad- 
vances steadily at its margin, and forms a swollen, deep- 
red patch upon which large vesicles and bullae form. 
The margin of eczema is ill defined, fading off into the 
surrounding skin ; its vesicles are pin-point- to pinhead- 
sized ; itching is always present ; and there is little or 
no constitutional disturbance. Eczema has a dry, rough 
surface in the erythematous form, while erysipelas has at 
first a smooth and shining one. 

Erythema burns rather than itches ; its redness can be 
entirely squeezed out by pressure, leaving a whitish spot, 
and returns promptly when the pressure is removed. 
In eczema pressure will cause the redness to disappear, 
but it will leave a yellow stain in its place. Erythema 
lacks the itching, exudation, scaling or crusting, and 
cracking of eczema, is prone to appear upon the back 
of the hands and wrists, and is symmetrical. 

Herpes febrilis resembles eczema only in having vesi- 
cles upon a red surface. It occurs usually in a single 
patch upon the face ; its vesicles are discrete, and show 
15 



226 DISEASES OF THE SKIN. 

little tendency to run together ; its course is short, and 
it pains or burns, but does not itch. 

Zoster occurs in the form of a number of herpetic 
patches following the course of a nerve, and occupying 
only one side of the body — symptoms that are entirely 
foreign to eczema. 

Impetigo contagiosa occurs for the most part upon the 
face, hands, and exposed parts. Its pustules are large, 
flat, and discrete, not small and conglomerate. Its 
crusts are thin and stuck on ; not greenish and thick, 
as in eczema. It is a vesi,co-pustular disease, and often 
presents large vesicles or bullae that look like burns of 
the second degree. 

Lichen planus presents papules that are flat, smooth, 
umbilicated, and angular, and has a peculiar violaceous 
hue when its lesions are sufficiently numerous to simulate 
eczema. Eczematous papules are round and acuminate 
and bright red. They are constantly coming and going, 
while those of lichen planus are constant and last for 
a considerable time. 

Lupus erythematosus occurs in sharply defined patches 
which are exceedingly chronic ; its scales are adherent ; 
its color is peculiar ; and it produces atrophy of the skin. 
Eczema presents none of these symptoms. 

Mycosis fungo'ides in its early stage is often indistin- 
guishable from eczema. Usually its patches assume a half- 
moon, horseshoe, or kidney shape. These may disappear, 
to reappear in the same or other locality. They also fail 
to respond to treatment. The diagnosis is at times dif- 
ficult until the characteristic elevated patches appear. 

Pemphigus foliaceus presents raw surfaces that bear 
some resemblance to eczema rubrum ; but its large bullae 
and pastry-like crusts, coupled with the generally bad 
condition of the patient, sharply differentiate it. 

PhthiriasiSy or pediculosis, shows parallel scratch-marks 
over the shoulders and excoriations about the waist and 
on the limbs where the seams of the clothing come. If 
on the head, the lesions will be on the occiput, and nits will 



ECZEMA. 227 

be found on the hair of that region or of the temples. 
The eruption to which they give rise is an eczema, but 
the cause of it is evident. 

Pityriasis rubra pilaris has elevated papules about the 
hair follicles of the back of the fingers, and is not particu- 
larly pruritic. It forms well-defined patches that feel 
like nutmeg graters and present no secondary changes. 

Pruritus cutaneus has no lesions, properly speaking, 
and the excoriations met with are not in patches, but scat- 
tered all over the body at intervals and irregularly. The 
itching is more paroxysmal than it is in eczema, and the 
itching is the only symptom that it has in common with 
eczema. 

Psoriasis, Avhen occurring in typical round or oval, 
sharply defined patches, with silvery scales, offers no dif- 
ficulty in diagnosis from a typical eczema. From circum- 
scribed eczema, that occurs occasionally, it may be diag- 
nosticated by the color — of a brighter red ; by the scaling, 
that is whiter, thicker, and more laminated ; and by find- 
ing characteristic patches either of the one or the other 
disease elsewhere on the body. When psoriasis occurs in 
large areas it is diagnosticated from squamous eczema by 
its sharply denned border; its marginate form ; its brighter 
red; its more abundant, thicker, and whiter scales; its fond- 
ness for the extensor surfaces of the limbs, while eczema 
seeks the flexor aspects and the flexures of the joints ; its 
uniform character and constant dryness, against the poly- 
morphous character of eczema and its moisture; and its 
history of frequent relapses, always of the same sort and 
always on the elbows and knees. 

Rosacea occupies the middle third of the face from 
above downward, attacking the forehead, nose, and chin ; 
while eczema affects the whole or part of the face, but 
never occurs on these limited regions alone; it burns 
rather than itches ; it shows telangiectases, and its red- 
ness and occasional discrete, sluggish, superficial pustules 
are very different from either the dry, harsh, scaly, red- 
ness of an erythematous eczema, or the crusted surface of 
a pustular eczema. 



228 DISEASES OF THE SKIN. 

Scabies may be diagnosticated from eczema, by its loca- 
tion upon the anterior surface of the wrists, between the 
fingers, and upon the abdomen and buttocks of both sexes, 
and upon the nipples and breasts of women and the penis 
of men. In children the feet are often affected. The 
presence of cuniculi is diagnostic, but they are hard to 
find in some cases. The eruption in scabies is at times 
an eczema ; but it is important to recognize, where pos- 
sible, the cause of an eczema in order to cure it. 

Syphilis, like eczema is a protean disease ; but it does 
not itch, and that is an important point in differential 
diagnosis. It is true that occasionally a papular or crusted 
pustular syphilide does itch, but the occurrence is so rare 
that it need not here be taken into account. The early 
syphilides are general eruptions, whether macular, papu- 
lar, or pustular, and the efflorescences never form patches, 
though they may show more or less grouping. When the 
other symptoms of syphilis are present, such as the initial 
lesion, mucous patches, and alopecia, there can be no diffi- 
culty. It is the later manifestations of the disease that 
offer difficulties in diagnosis, and especially the grouped 
papular lesions that occur on the palms in the form of scaly 
patches. In some cases a diagnosis is impossible. The 
most suggestive symptom of syphilis is the occurrence of 
the disease upon the palm of one hand alone. The patch 
will have a wavy outline ; will be scaly, but not moist 
or crusted ; will often show healthy skin in the middle ; 
and there are apt to be isolated, scaly, dark-red papules 
somewhere in the neighborhood. The finding of scars 
of old lesions, or some other evidence of syphilis, will 
aid us. 

Trichophytosis corporis when in disk-shaped patches 
that have not formed rings bears at times so close a resem- 
blance to eczema that it is difficult to make a diagnosis at 
once ; but in a short time the centre of the disk will clear 
up and the annular ringworm patch will declare itself. 
Eczema does not have annular patches. 

Urticaria , when it has induced itching and has been 



ECZEMA. 229 

scratched, looks like an eczema. We recognize it by the 
finding of the wheals, or the history of them, and by the 
isolated, scattered distribution of the excoriations and 
papules. Some cases of papular urticaria can only be 
diagnosticated after prolonged observation. 

Treatment. While not a few cases of eczema arise 
from purely local causes, and require only external treats 
ment, in most cases the patient is not in good condition, 
and he needs treatment quite apart from his skin disease. 
It is well for us to begin the treatment of a case by regard- 
ing it as one of a sick man rather than a sick skin. The 
better practitioner of medicine a man is, the better his 
chances of curing eczema will be. It is not the part of 
the writer on matters dermatological to instruct his readers 
in general medicine, and here I can give only an outline 
of the treatment proper to be followed. 

If the patient is anaemic, we should administer iron, 
and see that he has plenty of fresh air and a sufficient 
amount of exercise. If he is run down, and especially 
if he is of a strumous habit, cod-liver oil will be indi- 
cated. To the nervous patient, strychnin, hypophos- 
phites, and other nerve tonics should be administered. 
The dyspeptic needs mineral acids, mix vomica, pepsin, 
or bismuth and soda, according to the different form the 
trouble takes. Those suffering from uterine diseases 
need the treatment best suited to their case. The gouty 
and rheumatic w r ill be benefited by alkalies, such as the 
acetate of potash or the phosphate of soda. Colchicum 
will be useful in gouty cases. In fact, there is no specific 
for eczema, and each case should be studied and treated 
by itself. 

But nearly every case requires attention to the diet 
and exercise, and to the proper action of the bowels and 
kidneys. The diet is of special importance. Piffard * 
has found that 56 per cent, of his cases of eczema have 
been carnivorous — that is, eating meat three times a day 

1 Materia Medica and Therapeutics of the Skin. Wm. Wood & 
Co., N. Y., 1881. 



230 DISEASES OF THE SKIN. 

and but little bread and vegetables ; 40 per cent, om- 
nivorous, and but 4 per cent, herbivorous. Many of 
the patients eat too much and exercise too little. Many 
suffer from distress of stomach after eating certain arti- 
cles. Some eat too little, and that of improper sort. The 
indications for treatment are therefore obvious. The 
greatest difficulty we have to contend with is the objec- 
tion most people have to dieting of any sort. 

In an acute eczema of any considerable extent it is 
always best to put the patient on a restricted and simple 
diet, and of these, where milk is well borne, a milk diet 
is the best. Two or more quarts of milk may be taken 
during the day in divided doses, with dry toast or toasted 
crackers and the cereals, excepting oat meal. After a 
few days a more liberal diet may be allowed, as in sub- 
acute and chronic eczema. 

In subacute and chronic eczema meat should be taken 
but once a day, and should be beef, mutton, or chicken, 
and these should be eaten in the middle of the day when 
possible. Breakfast and supper should be very simple, 
of crackers and milk, br£ad and milk, or some of the 
grains well cooked and eaten without sugar. There is a 
popular idea that oatmeal is injurious. It is best to forbid 
its use. Fish may be allowed, but not those with dark 
meat or oily. An occasional egg may be eaten in the 
morning, but not every day. No pastry, cake, or con- 
fectionery should be allowed. Apart from absolute sim- 
plicity, the patient's taste may be consulted, care being 
taken to avoid anything that he knows will disagree 
with him. It is a good rule to tell the patient that he 
may eat what he likes, in reason, but not of more than 
three dishes at a meal. It is unlikely that he will then 
overeat. Those who eat too little for any reason should 
be directed to take that little more often during the day. 
Butter may be taken freely. The dyspeptic should drink 
a cup of hot water about a half-hour before meals. It is 
sometimes necessary for a time to resort to kumyss or 
matzoon, and artificially digested food, but the sooner he 



ECZEMA. 231 

can return with comfort to a more natural diet the better. 
Fried and warmed-up meats should be avoided in all 
cases. Fruits fully ripe or stewed can as a rule be liber- 
ally partaken of. 

All alcoholic drinks must be absolutely forbidden. 
Malt liquors are especially obnoxious to all irritable 
skins. Tea, coffee, and chocolate are best let alone. 
Coffee, one small cup, may be allowed for breakfast ; or 
cocoa which is better, if made with a good deal of milk. 
Milk, if it does not constipate, may be allowed, but not 
with the regular meals if the patient is on a usual mixed 
diet. Water should be drunk regularly, and it is not un- 
likely that much of the benefit derived from visiting 
foreign spas is due to the regular drinking of water. A 
good rule is for the patient to drink a glass of water 
before meals, while dressing, a glass of water or other 
fluid at each meal, a glass of water about two hours after 
meals and before going to bed. If preferred, bottled 
table waters may be used. Vichy water may be substi- 
tuted for plain water once or twice a day. Tobacco is 
harmful in some cases. 

Enforcement of these dietary laws will in many cases 
overcome constipation. It is best not to resort to medi- 
cines to procure a good daily movement of the bowels, 
if it can be avoided, but to exercise, and the formation of 
the habit of going to stool at a regular hour of the day. 
If we must needs give medicine, the tablet triturates of 
aloin, belladonna, and dux vomica ; the pill of iron and 
aloes ; the extract of cascara sagrada, with or without 
mix vomica, which may be administered in capsules or 
as compressed tablets to avoid the disagreeable taste ; 
Starting mixture — 

B; Magnesii sulphatis, o YJ-^jss ; 20-30 

Ferri sulphatis, <£j ; 4 



Ac. sulphur, dil., ^ij; 8 

Syr. pruni virgin., %j ; 30 

Aquae, ad ^iv; ad 120 

Sig. A teaspoonful through a tube, after meals. 



M. 



232 DISEASES OF THE SKIN. 

or any other serviceable remedy may be given. Harda- 
way recommends the phosphate of sodium, a teaspoonful 
in hot water before breakfast, or three times a day, for 
lithsemic patients who are constipated. This is an ex- 
cellent laxative for children, a little of it being put into 
their milk, to which it gives a hardly noticeable taste. 

Exercise in the open air is as necessary for eczematous 
patients as for any other class. It should not be taken 
so as to cause over-fatigue. Patients with eczema on the 
face and hands, or with a tendency thereto, should 
always protect the skin by a little powder, calamine 
lotion, or cold cream before going out into the cold, or 
storm of wind or rain. 

Though there is no specific for eczema, there are certain 
drugs that have acted favorably upon the disease in the 
hands of some observers. Arsenic has come down from 
old with a reputation for curing eczema, and is largely 
prescribed. It had best be let alone. It is only of benefit 
in chronic scaling cases, and in only a few of them. It 
may be used in the form of Fowler's solution (liq. 
potassii arsenitis), giving from 2 to 5 minims well diluted, 
three times a day, after meals ; or as arsenious acid, in 
tablet triturates, either with or without pepper, dose -g\ 
to -g 1 ^ grain. The wine of antimony in 5-minim doses, 
three times a day, has been warmly commended. Phos- 
phorus, T | ¥ to %\ grain, either in pill or in oil, has been 
found useful in long-standing eczema. Piffard speaks well 
of an infusion of Viola tricolor in acute or chronic eczema 
capitis, especially in lymphatic children. It is made by put- 
ting one or two drachms of the imported herb into a bowl, 
pouring a pint of hot water over it, and covering with a 
plate. When cool, it is to be taken in divided doses dur- 
ing the day. After a few days it generally aggravates 
the disease, a good thing to accomplish in chronic cases. 
It is then to be discontinued for a few days or a week. 
In acute cases the dose should be quite small. In infants 
1 drop two or throe times a day is often sufficient. 
Adults may take as much as a teaspoonful in chronic, 



ECZEMA. 233 

sluggish cases. Turpentine, the spirits, is recommended 
by Crocker in obstinate cases. It is given in an emulsion 
with mucilage, three times a day, after meals, the dose 
being 10 minims at first, and then, if tolerated, increased 
by 5-minim doses up to 20 or 30 minims. While it 
is being taken not less than a quart of barley-water 
should be drunk, and the last dose should be taken not 
later than six o'clock in the evening. The same author 
recommends counter -irritation over the spine, the nape 
of the neck for eczema of the upper half of the body, 
and over the last dorsal and first lumbar vertebrae for the 
lower half. Dry heat, a mustard-leaf, or liquor epispas- 
ticus may be used. I have seen most excellent effects 
from this plan. The spinal ice-bag sometimes accom- 
plishes the same result. 

In acute eczema, if taken early, sharp catharsis will 
sometimes tend to lessen the severity of the attack by 
reducing the congestion of the skin. In chronic eczema, 
even without evident renal derangement, the acetate of 
jMash in 15-grain doses will prove useful. The itch- 
ing may be so severe in some cases that even our local 
remedies may not allay it, and it may seem necessary to 
give some medicine to procure sleep. Never use opium. 
The bromides, chloral, or phenacetine may be given. Hyde 
and Montgomery speak well of calcium chloride in full 
doses. Bulkley recommends tincture of gelsemium, of 
which 10 drops are to be given, and repeated and increased 
every half-hour till relief is obtained, or constitutional 
symptoms of languor, tranquillity, dizziness, impairment of 
vision, and drooping of the lids, are produced. Quinine, 
in J-grain to 15-grain doses, given at bedtime, is com- 
mended by some for the same purpose. 

Rest in bed is desirable in all severe cases of eczema 
whether they are acute or exacerbations of chronic forms. 

Local Treatment. In all cases, whether due to 
purely local causes or a combination of these and some 
general cause, local treatment is of the greatest importance. 
The books teem with prescriptions which have been found 



234 DISEASES OF THE SKIN. 

efficacious, and some of them contain so many ingredients 
that it is hard to determine with exactness to what the 
benefit is due. After all, the matter is very simple, and, 
if the principles are mastered, little difficulty will be found 
in accomplishing the desired end. In acute cases, where 
we have heat and swelling, employ soothing remedies; in 
subacute cases, where the swelling has subsided and where 
the papulation, vesiculation, pustulation, or exudation is 
more or less active, use astringent and protective remedies; 
in chronic cases, where we have thickening with scaling, 
stimulate; in all cases protect the shin from external irrita- 
tion. It is better to learn how to use a few remedies and 
to know what to expect from them, than to try every new 
method that appears in the medical press. 

It is a good, broad rule that water should not be used 
on an eczematous skin, as it removes the newly formed 
epidermis and exposes the tender skin to the air. In all 
but chronic cases it should be used sparingly, and only to 
remove dirt, or crusts, or scales, and the skin should be 
at once covered with some protecting powder or ointment. 
If water is used, it should be either rain or boiled water, 
or water with a little soda, one drachm to the basinful, or 
with bran in it. Often it is better to clean the skin with 
an oily lotion than to use water. 

In acute eczema lime water, liquor plumbi subacetatis 
dil., lead-and-opium wash, or solutions of- borax and 
soda, 1 or 2 drachms to the pint, may be sopped on 
three or four times a day, dusted over with cornstarch, 
compound stearate of zinc, dolomol, bismuth, lycopodium, 
kaolin, or French chalk, and covered with light, old 
linen or muslin. All these will allay the itching ; but 
if this is especially severe, the following may be used : 



M. 



U Camphori, 


3ss; 


2 


Zinci oxidi, 


m ; 


18 


Amyli, 


3iv; 


ad 30 



Startin recommends the following 



ECZEMA. 




Zinci oxidi, ^ss; 
Pulv. calaminae praep., ^iv ; 
Glycerini, ^j ; 
Liq. calcis, gvij ; 


10 

5 

40 

ad 100 



235 



M. 

As soon as the early and most acute stage is passed — 
that is, in subacute eczema — a protecting and soothing 
ointment is to be used, and of these no one is safer than 
the standard benzoated oxide of zinc ointment that 
usually can be obtained anywhere. The cucumber oint- 
ment is also soothing. If the case be one in which there 
is much discharge, as in pustular, vesicular, and weep- 
ing eczemas, Lassoes paste is better than the oxide of 
zinc ointment, as being a paste it allows the discharge to 
percolate through it. It is made as follows : 

K Zinci oxidi, \ aa gij I aa 81 

Amyli, J gss; 16J M. 

Vaselini, 

The addition of 10 to 15 grains of salicylic acid to the 
ounce increases its antipruritic quality, but it is often 
too stimulating and must be used with caution. The 
only difficulty is that it takes time and muscle to make, 
and but few druggists make it well. See that in it, as 
in all other ointments, there are no gritty particles left. 
All ointments must be smooth, or they do harm rather 
than good. In using ointments in eczema they should 
be evenly spread upon cheesecloth folded four times, or 
upon old washed muslin, in a layer as thick as the back 
of a table-knife blade, applied to the affected part and 
bound down snugly with a bandage. They should be 
changed twice a day, or more often if the discharge is 
profuse. 

Painting a limited moist patch of eczema with a solu- 
tion of nitrate of silver, 3 to 10 grains to the ounce, is 
often a most prompt method of curing the disease. 

Ointments are objectionable on account of their greasi- 
ness, and where possible it is pleasanter to use lotions. 
Of these, one of 



gr. xx ; 


1 


ZU 


3 


3iv; 


12 


3vj 


18 


ad ^iv; 


ad 100 



236 DISEASES OF THE SKIN. 

R Calamin., 
Zinci oxid., 
Glycerin. , 
Aquae calcis, 
Aquae rosae ad ^iv; ad 100 M. 

answers well. To this may be added carbolic acid in 
1 to 5 per cent, strength to relieve the itching. Per- 
oxide of hydrogen sopped on exercises a beneficial 
effect on pustulation. In using lotions in cold weather 
the patient should be advised to warm them to avoid 
chilling the skin. 

The diachylon ointment of Hebra will often prove 
beneficial, especially after the subsidence of acute symp- 
toms. It is the best used diluted with ungt. aqua? rosae 
in the proportion of 2 parts to 1. Most cases that 
we are called upon to treat are in or near to the subacute 
stage, as the acute stage soon passes off. It is always 
advisable to begin treatment not too boldly. If our 
protecting and astringent remedies do not cure the case 
after a fair trial, then we must add stimulants, and of 
these one of the most reliable is tar, adding it at first in 
the proportion of about 15 drops of the oil of cade to the 
ounce of ointment-base, such as oxide of zinc ointment. 
Ichthyol, thiol and thigenol may be used in 10 per cent, so- 
lution in water during this stage. The last is a good anti- 
pruritic, and they all form protective varnishes on the skin. 
In chronic squamous eczema we need stimulation to 
whip up the circulation, to produce absorption of the in- 
filtration of the skin, and to promote a return to health. 
Here tar is one of our most reliable remedies, and it can 
be used in the various strengths and ways. We may use 
oil of juniper, oleum cadini, the oil of birch, oleum rusci y 
or pix liquida. There is some doubt and difficulty about 
obtaining genuine oleum rusci, which is largely used by 
tanners in the preparation of Russia leather. The oil of 
cade is most used. Some prefer this ointment . 
R 01. cadini, ^ss-j ; i ^a 2-4| 

Zinci oxidi, gss-j ; J 

Uguenti. aquae rosae ad £j ; ad 32 1 M. 



ECZEMA. 237 

Or the cade may be added to the oxide of zinc ointment 
in the proportion of 1 drachm to the ounce. Or pix 
liquida may be substituted in about double the strength. 

Another most excellent way of using tar, and prefer- 
able to the latter, because not so liable to stain the 
clothing, is that proposed by Pick, namely, to make a 
strong tincture of tar, using 40 parts of pix liquida to 
20 parts of alcohol ; and to paint the part every night 
with 3 coats of this tincture, letting each coat dry on 
before another is applied. Then cover with oxide - of 
zinc ointment ; the ointment being changed morning and 
night. 

Bulkley in some cases recommends tar in what he 
names liquor picis alkalinus, which is made as follows : 
}£ Picis liquidae, ^ij ; 40 

Potass, causticae ^j ; 20 

Aquae, ad ^v ; ad 100 M. 

Dissolve the potash in the water and add slowly to the 
tar in a mortar with friction. This is to be used diluted 
20 or more times with water, and followed by oxide of 
zinc ointment. 

In some very chronic, thickened eczemas the tar may be 
rubbed in pure. If the eczema is very extensive, the tar 
may be used in olive oil or cotton-seed oil and smeared 
over the body. In some cases the tar will give rise to 
systemic poisoning, the urine will become black, and the 
patient will suffer from headache, oppression, nausea, 
vomiting and diarrhoea, and the pulse will become fre- 
quent. Of course, under these circumstances the tar 
must be stopped. 

Sulphur is, next to tar, one of our best stimulating 
remedies in squamous eczema. It is not so reliable, as it 
is more uncertain in its effects. It finds its best use in 
circumscribed patches, and may be used in vaseline or 
simple ointment in the strength of 1 or 2 drachms to 
the ounce. In some skins it produces a good deal of 
dermatitis. 

Green soap is often of the greatest service in chronic 



238 DISEASES OF THE SKIN. 

eczema. It is to be used in the following way : Take 
green soap ; warm water ; and oxide of zinc ointment 
spread on muslin or linen. Dip a piece of flannel in the 
soap and then in the water, and then with it scrub the parts 
vigorously until all the scales are removed and the skin 
looks somewhat raw. Now wash off all the soap with 
plenty of water, dab the part dry with a soft towel, im- 
mediately cover with the ointment, and apply a band- 
age. The soap is to be used once a day and the oint- 
ment changed twice a day. 

Caustic potash, 15 grains to 1 drachm to the ounce; 
or salicylic acid, 10 to 20 per cent., in ether, may be used 
to reduce very much thickened patches. Nitrate of silver, 
10 to 15 grains to the ounce, may also be used ; or chrysa- 
robin, 10 per cent. 

Unguent, hdyrarg. ammoniat. is of use in chronic ec- 
zema of limited area. 

Ichthyoly thiol, thigenol, and resorcin are more recent ad- 
ditions to our armamentarium. The first has a more 
disagreeable odor than tar, and, as Crocker says of it, 
"We do not want more of such remedies, as tar fills that 
place so well ; what is required are remedies which do not 
stain nor smell." In chronic, thickened eczema a 40 to 
50 per cent, aqueous solution of ichthyol, well rubbed in 
once a day with a stencil or stiff paint-brush, acts admir- 
ably. Both thiol and thigenol are artificial ichthyol, 
possessing its good qualities without its odor, and may 
be used in the same way. Resorcin in from 2 to 5 per 
cent, strength is a good stimulating application. 

For the reduction of infiltration and removing the scales 
in a chrome eczema nothing is better for a time than sheet 
rubber applied to the part and bound down with a roller 
bandage. The rubber should be removed once a day, 
sponged off with soda and water, and reapplied. The re- 
lief to the itching procured by this means is sometimes 
surprising. As soon as the infiltration is reduced we 
should resort to our tar remedies for completion of the 
cure. 



ECZEMA. 239 

Many attempts have been made to find a substitute for 
greasy or oily applications in the treatment of skin dis- 
eases. Thus we have the plaster mulls of Unna, in which 
a plaster mass is incorporated with the mulls. Many 
speak loudly in their praise. Then collodion and traumat- 
icin have been used, and answer well, the tar, salicylic 
acid, or what not, being dissolved or held in suspension. 
In this way chrysarobin may be used on limited patches 
of chronic eczema. Gelatin preparations are very valu- 
able, and applied either to a subacute or chronic patch, 
especially when there is no moisture, will allay the itch- 
ing and hasten the cure. Unna's gelatin paste sets at 
once. It is composed of 

1£ Zinci oxidi, 30. 

Gelatini, 30. 

Glycerini, 39. 

Aquae, 10. M. 

It forms a hard mass that must be melted before it is 
used. The best way to use it is to put it in a small tin 
saucepan that fits into another pan that holds water, such 
as is used for sterilizing milk or cooking oatmeal gruel. 
This can be heated over a Bunsen burner or spirit lamp. 
When melted and still warm, it is to be painted over the 
part under treatment by means of a wide paint brush. 
Immediately over it place a layer of absorbent cotton, and 
over all a roller bandage. This dressing may be left on 
for two or three days. The gelatin may be used as an 
excipient. Gelanthum is an ointment base that does not 
contain lard or oil and is a good excipient. Medicated 
soaps have their advocates. 

In the treatment of eczema we must not content our- 
selves by simply giving our patient an ointment, but we 
must instruct him in the way he should use it. As a 
rule, and where possible, ointments should not be smeared 
on the skin, but spread on old linen, muslin, or the like, 
and bound down with a bandage or with a ring of elastic 
webbing. In chronic patches it is well to rub in the tar 
or other ointment. 



240 DISEASES OF THE SKIN. 

Massage sometimes does good service in reducing infil- 
tration, the part being stroked upward, in the course of 
the circulation. 

Baths are not usually advisable in eczema, and are ap- 
plicable only to chronic cases. Good results have been 
reported from some sulphur baths. Residence at the sea- 
side generally proves bad for eczematous patients, but it 
may be a good thing for some run-down patients, the tonic 
effect of the sea air out-balancing the evil effects of the 
dampness. Soda, borax, or bran baths will prove grate- 
ful in some cases. Bulkley orders the following : 



R Potass, carbonat., 


3iv; 


130 


Sodii carbonat., 


giih 


100 


Boracis pulveris, 


sij; 


70 



M. 

Add to thirty-gallon bath with half a pound of starch. 

The a>ray is at times useful in chronic, thickened, obsti- 
nate patches of eczema. A moderately soft tube is to be 
used with feeble light, the patient is to be seated from 
eight to fifteen inches distant from the target, and the time 
of exposure should be about three to six minutes. The 
sittings are to be given twice a week for two weeks and 
then suspended, and results waited for. The high-fre- 
quency current, D'Arsonval, allays the itching and tends 
to dissipate the patches. It may be used two or three 
times a week, the tube being passed over the patch in 
contact with the skin, or at a little distance from it, ac- 
cording to the amount of stimulation desired, and the 
ordinary applications continued between times. 

Prognosis. We can give assurance of curing eczema 
so far as the attack with which the patient comes to us is 
concerned. We can give no positive assurance that the 
disease will not return. The cure of the attack requires 
patience, careful study of the case, and the intelligent use 
of remedies. But there are some cases that are exceed- 
ingly rebellious. We have to accept the fact that some 
people are " eczematous," and that they cannot be perma- 
nently cured unless they are regenerated. We should 
cure our cases as rapidly as possible, and not take refuge 



ECZEMA, 241 

in the excuse of the incompetent man and tell the patient 
that it is dangerous to cure eczema. 

We must now consider Regional Eczema. 

Eczema Ani, as usually met with, is of the squamous, 
thickened variety with Assuring. It may also be moist. 
It usually extends up the whole internatal fold. It gives 
rise to great pain in defecation and to mucli itching at 
all times. The discharge from this form, as well as from 
eczema of the genitals, is frequently offensive, owing to 
the decomposition of the sebaceous secretions. Excessive 
use of tobacco predisposes to this variety of eczema, prob- 
ably on account of the nervous irritation inducing itch- 
ing, for the relief of which the patient scratches and pro- 
duces the eczema. Other predisposing causes are all 
those that cause pruritus ani, which see. 

In treatment the first thing is to stop the use of to- 
bacco, a hard task, as the patient is oftthnes incredulous 
of its efficacy. Horseback riding and much walking 
will sometimes have to be stopped, as they may aggra- 
vate the trouble. If hemorrhoids or fissures of the mu- 
cous membrane are present, as they quite frequently are, 
they must be cured in order to obtain a permanent cure 
of the eczema. The bowels must be kept easy by laxa- 
tives, so that one soft movement may be had each day. 
Liver derangements must be corrected to prevent portal 
congestion, and dieting will be of service. The nates 
must be separated by folds of lint, and the parts kept 
scrupulously clean, though water should be used as spar- 
ingly as possible. The itching may be relieved by sop- 
ping on hot water, dabbing the part dry, and making the 
chosen application. Tar or diachylon ointment may be 
used covered with a dusting powder. Usually the drier 
the parts can be kept and the less ointment is used the 
better. Painting a limited surface with salicylic acid, 
10 to 15 grains in an ounce of flexible collodion, is 
often followed by the happiest results. Painting with 
nitrate of silver, 10 to 15 grains to the ounce, is some- 
times advisable. Here, too, if there is much thick- 
16 



242 DISEASES OF THE SKIN. 

ening, wearing rubber cloth for a few days or using a 
salicylic acid plaster will greatly hasten the cure. A 
well-applied ~f -bandage is the best way of keeping the 
dressing in place. Thigenol, 50 per cent, solution in 
water, often acts well. It stops the itching, stimulates 
the skin, and, as it dries on the skin, does away with the 
use of ointments. 

Eczema Aurium. Eczema may affect both the ear 
itself and the inside of the auditory canal. When the 
ear is acutely affected, it is swollen at times so much as 
to stand out from the head. In acute eczema of the ex- 
ternal auditory canal, which is secondary to that of the 
auricle, the swelling may be so great as to cause dulness 
if not loss of hearing. Of eczema of the outer part of 
the ear nothing special need be said excepting that the 
dressings must be exactly applied to all the little fur- 
rows of the ear, and a pledget of lint placed in the fur- 
row behind the ear, thus separating it from the side of 
the head, so that in sleeping the two surfaces of skin do 
not come in contact. Painting this part of the ear with 
a solution of nitrate of silver, 10 grains to the ounce, 
will sometimes aid greatly in converting a moist eczema 
into a squamous one. A cure will be hastened by hav- 
ing the ear covered with a linen bag made in the fashion 
of an ear-muff. Eczema of the auditory canal is some- 
times very annoying on account of an accumulation of 
scales, dulling the hearing. Eor this condition an oint- 
ment of tannin, 1 drachm to the ounce, or a solution 
of nitrate of silver, 5 to 20 grains to the ounce, 
may be applied thoroughly by means of absorbent cotton 
on a probe, the ear being properly lighted by means of 
a head-mirror, and the operator having the requisite 
skill. Otherwise the tannic acid ointment, or one of 
oxide of zinc, or the diachylon ointment may be applied 
on pledgets of lint rolled up to fit the orifice. It must 
be remembered thai: ointments mixed with the exfoliated 
epidermis of the canal, and forming a paste with it, tend 
to stop up the canal and produce deafness. Such deaf- 



ECZEMA. 243 

ness can be removed by syringing, or mopping with oiled 
cotton. The insufflation of boric acid will sometimes be 
better yet. The ear should not be syringed out often, 
and when it is necessary to do so a solution of borax or 
baking soda should be used. 

Eczema Barbce is scarcely ever confined to the bearded 
portion of the face, but it generally runs over onto the 
bordering skin, and is often but a part of eczema of the 
face. It has practically the same symptoms as has ec- 
zema capitis. It needs to be diagnosticated from ring- 
worm and sycosis, which see. In treatment, shaving, or 
cutting the hair close, which is better, should be practised 
so that remedies may be closely applied. Plucking the 
hair from the pustules is to be recommended. Its further 
treatment is the same as that of eczema capitis. It is an 
obstinate form of eczema, prone to relapses. 

Eczema Capitis. The scalp is very commonly the seat 
of eczema, either by itself or in connection with eczema 
elsewhere. It has received various names, such as crusta 
lactea ; porrigo ; melitagra ; scalled head ; milk crust ; 
or vesicular or running scall. While any variety of 
eczema may occur on the scalp, the vesicular is very 
rarely seen, and the most common is the pustular, and 
the final stage the squamous. In the acute stage the 
scalp may be swollen and boggy, and moist, with the 
hair stuck together. We may find the scalp crusted 
with a yellowish serous crust, but more commonly there 
is a greenish or blackish purulent crust, while the scalp 
is swollen but little. In some cases of pustular eczema 
there will be discrete, rather large pustules scattered 
through the hair, besides moist and crusted patches. 
The hair is always matted together, and the odor from 
the scalp is unpleasant. If the crusts are removed, they 
will soon reform. 

In both the erythematous and the squamous forms the 
scalp is red and scaly. In the latter variety there is apt 
to be more or less thickening of the scalp, and in very 
severe cases the scalp may be cracked. Not infrequently 



244 DISEASES OF THE SKIN. 

there will be squamous patches iu some places and moist 
aud crusted patches iu other places. 

With eczema of the scalp there is almost always ec- 
zema behiud the ears. The cervical glauds are very 
often swollen, especially in children, but they need give 
uo anxiety, as they very rarely suppurate. In the 
chrouic form there may be loss of hair, especially iu 
children, when it is sometimes mechanically rubbed off 
from the occiput. It is never permanently lost. All 
forms are itchy, the pustular form least so. The patient 
may complain of a "drawn" feeling of the scalp. As 
in all inflammatory diseases of the scalp, there is over- 
activity of the sebaceous glands, and the crusts will con- 
tain a certain amount of fat. In chronic cases there 
may be, on the other hand, a deficiency of fat. Pedi- 
culi are often found ou the hair. The disease may affect 
the whole scalp or only a portion of it, and may run an 
acute or chronic course. 

Etiology. The exciting causes of eczema capitis are 
all irritants to the scalp. Sometimes it is well-meant but 
badly directed efforts at cleanliness, especially in children. 
Combing with a fiue-toothed comb, too vigorous use of 
soap aud water, the use of a too stiff brush, or some of 
these. Pediculi are very often the cause — not the pediculi 
themselves, but the scratching to relieve the itching pro- 
duced by them. An eczema of the occiput should always 
suggest their presence, and search then will generally 
reveal the pediculi, or their nits upou the hair. Some- 
times remedies used to kill the lice will set up an eczema, 
such as strong mercurial ointments. In most cases eczema 
of the scalp is but a part of a more or less general eczema 
and due to the same causes. 

Diagnosis. The disease must be differentiated from 
pityriasis capitis, ringworm, erysipelas, lupus erythemato- 
sus, a dermatitis, psoriasis, seborrhcea, favus, pediculosis, 
and syphilis. See under these diseases. 

Treatment. The treatment of eczema capitis is along 
the same lines as is that of the disease in general. On 



ECZEMA. 245 

the scalp it is always best to use our remedies either in 
vaseline or oil, as preparations of lard make a disagreeable 
mess with the hair. Nor should a thick ointment ever 
be used, excepting perhaps in children before their hair is 
grown, or on bald heads. If there are crusts on the scalp, 
they must be removed before any local treatment is used. 
This may be done best by soaking them with sweet oil 
containing 1 or 2 per cent, of salicylic acid for twelve 
or twenty-four hours, and then washing them away with 
soap and water. Plenty of oil must be used, and it is well 
to tie the head up in a towel over night. A woman's or 
half-grown girl's hair should never be cut in order to treat 
the scalp. In applying remedies to the scalp, after the 
acute stage, they should be rubbed in, and not merely 
smeared over it. 

In acute eczema equal parts of lime-water and sweet or 
almond oil, with or without 1 or 2 per cent, of salicylic 
acid, form a good application. 

In subacute and chronic eczema of the scalp, tar, espe- 
cially the oil of cade, is our most reliable remedy. It 
must be remembered that it can be used much earlier on 
the scalp than elsewhere, and most cases will improve 
under it as soon as the acute stage is passed. It may be 
begun in the strength of 20 drops to the ounce of oil, 
and increased to 1 or 2 drachms to the ounce. Many 
people object to the odor of the tar. We can substitute 
for it : 

R Hydrarg. ammon. gr. xx; 5 

Vaselini, ad ^j ; ad 100 M. 
Or, 

R Ac. salicylici, gr. xx-xxx; 5-6 

01. olivae, ad ^j ; ad 100 M. 

The oil of cajuput in 5 to 10 per cent, strength may 
be tried. Neither of these is as good as tar. 

If the disease is in a chronic condition, shampooing with 
green soap or its tincture, followed by some oily, not very 
stimulating application, will prove curative. In this con- 
nection it is sometimes best to exhibit the tar in an alco- 



246 DISEASES OF THE SKIN. 

holic solution. Resorcin in 3 to 10 per cent, strength 
may be used cautiously in this way. If the scalp is 
cracked and thickened, great and prompt amelioration 
will be secured by having the patient wear a close-fitting 
cap of rubber. 

Eczema Crurum. Eczema of the legs acquires its pecu- 
liarities from the fact that the circulation of the parts is 
less active than it is in the upper portions of the body, 
on account of the action of gravity upon the returning 
venous blood. It usually is seen as an eczema madidans, 
though any form may be present. Varicose veins, either 
superficial or deep, predispose to it ; and an eczema aris- 
ing from such a cause is spoken of as varicose eczema. It 
is questionable if such a condition should not be called 
varicose dermatitis. It is attended with swelling and 
often great oedema. It is located principally on the lower 
part of the leg, and is often complicated by ulceration. 
Pigmentation of more or less dark-brown color follows 
or accompanies it, if of any chronicity, and occasionally 
purpuric spots will be scattered about the chronic patch. 
As to treatment, nothing special need be said except that 
it is always advisable to have the legs bandaged snugly 
from the toes to the knee, and that the best result will be 
attained when the bandaging is done by the doctor or a 
trained nurse. 

Eczema Genitalium often causes a great deal of discom- 
fort on account of the excessive itching that accompanies 
it. It affects the scrotum most commonly, which in some 
cases will be greatly thickened and feel like leather. The 
skin of the penis also suffers at times as well as the glans. 
In women, both the lesser and the greater lips of the 
vulva, as well as the entrance to the vagina, may be 
affected, and show excoriations and thickening. All 
forms of eczema may be encountered in the genital 
region. In chronic eczema of the penis the organ be- 
comes greatly enlarged both laterally and longitudinally, 
on account of the thickening of the skin. The disease 
may be confined to the genitals, or extend to the thighs 



ECZEMA. 247 

or the anal region. The presence of diabetes should 
always be suspected in a case of this kind, and the urine 
should be examined for sugar. Leucorrhoea is a common 
cause of the disease in women. 

Treatment. In the treatment of eczema of the geni- 
tals, apart from that appropriate to general conditions, 
and specially to diabetes, it is essential that men should 
wear a well-fitting suspensory bandage, inside of which the 
dressing may be placed. The itching may be greatly 
relieved in all forms by directing the patient to sit over 
a vessel containing hot water and to sop the water up on 
the parts. In subacute eczema the skin should be mopped 
dry, the oxide of zinc ointment, diachylon ointment, or 
Lassar's paste immediately applied, and the suspensory 
bandage adjusted. Carbolic acid, 1 or 2 drachms to 
the ounce of glycerin and water, may also be used, lightly 
dabbed on, for the purpose of allaying the itching. It 
should be followed by either of the above ointments. For 
chronic, thickened eczema, wearing sheet rubber inside of 
the suspensory bandage will give positive and immediate 
relief, and greatly reduce the thickening. After a few 
days it is well to follow it with a tar or resorcin ointment. 
The use of the tincture of tar, as spoken of under chronic 
eczema (page 237), is often most serviceable. In some 
cases nothing will do so well as the application of the nitrate 
of silver solution, already given. The spirit of nitrous 
ether may be used as an excipient of this. Hardaway 
speaks highly of rubbing the scrotum with a solution of 
salicylic acid in alcohol, 1 drachm to the ounce, and 
following this with a boric acid or diachylon ointment. 

Women should use a "["-bandage instead of a suspen- 
sory. Otherwise the treatment is the same. In them I 
have seen the nitrate of silver treatment do remarkably 
well. 

Eczema Intertrigo occurs wherever folds of skin come 
in contact. It usually follows a simple intertrigo, dif- 
fering from it in having a discharge that stiffens linen, 
and in its pruritus. In its treatment the parts should 



248 DISEASES OF THE SKIN. 

be kept separated and as dry as possible by means of a 
dusting powder, or by placing a piece of old linen or 
cheesecloth between the apposed folds of skin. For a 
dusting powder we may use cornstarch either alone or 
with bismuth or zinc oxide ; lycopodium is also an 
excellent powder ; but the best powder of all is the 
compound stearate of zinc. Kaposi has seen gangrenous 
and diphtheritic inflammation begin in an intertriginous 
eczema. As a rule, these cases do best without ointments. 
This does not apply to eczema intertrigo of the crotch. 
Here it is well to cover the parts with a greasy applica- 
tion, so as to protect them from the action of the urine. 
A dilute diachylon ointment often answers admirably. 

Eczema Labiorum is usually due to nasal catarrh, and 
can be cured only when the cause is removed. Eczema 
may occur about the mouth in an orbicular manner. 
Many people suffer from chapped lips, especially in 
winter. This is an eczema of the vermilion border. For 
this little can be done except to caution the patient 
against moistening the lips. Greasing the lips every 
night with camphor-ice or the like keeps them in good 
condition. Glycerin agrees well with some skins, and is 
harmful to others. The lip may be painted with com- 
pound tincture of benzoin. 

Eczema Mammarum et Mammillarum. One of the 
most annoying accidents to befall a nursing woman is 
eczema of the nipples. They become excoriated and 
fissured, the cracks sometimes extending to the base of 
the nipple. At times a drop of pus can be squeezed 
from the bottom of the crack. They are exquisitely 
sensitive, and every time the baby takes hold the woman 
suffers agony. The moisture of the child's mouth and 
the decomposing milk left on the nipple aggravate the 
trouble. Mastitis may complicate matters. In the in- 
tervals of nursing the nipple scabs over. Either one or 
both nipples may be affected. The disease may extend 
onto the breasts, or the breasts may be affected independ- 
ently of the nipples. Women with pendulous and heavy 



ECZEMA. 249 

breasts frequently suffer with a moist eczema in the 
sulcus beneath them. Apart from this, nothing special 
need be said about eczema of the breasts. There is one 
disease of the breasts called Paget' s disease of the nipple, 
which at first very closely resembles eczema, and it is a 
question whether it is carcinomatous all the way through 
or an eczema developing into a carcinoma, (See Paget's 
disease, for diagnosis.) 

Treatment. It is often possible to cure eczema of 
the nipples even while the child nurses. Sometimes it 
will be necessary to wean the child. Women during the 
latter months of pregnancy should handle their nipples 
every day and bathe them with whiskey or alcohol, to 
which may be added 20 or 30 grains of borax to the 
ounce. This will do much to prevent further trouble. 
The suckling having begun, the nipples should be care- 
fully washed off and dried with a soft handkerchief after 
each nursing, and dressed with oxide of zinc or diachylon 
ointment should eczema show itself. Of course, the oint- 
ment should be removed before the infant is put to the 
breast, and this should be done with as little water and 
as much gentleness as possible. If there are cracks, the 
child should nurse through a rubber nipple, and when it 
lets go the nipple should be dried and painted with 
compound tincture of benzoin, or the solution of nitrate 
of silver already spoken of. It is also advised to touch 
the cracks with the nitrate of silver stick. This is very 
painful, and of little use as long as the infiltration of 
the nipple that causes them continues. The nipples may 
be washed with a borax solution and covered with an 
ointment of boric acid. It is always advisable to use noth- 
ing that is poisonous in the dressings. Hardaway re- 
commends the following for eczema under the breasts : 

R Thymol., gv. j ; |065 

Pulv. zinci oleat., 3 j ; 32 1 M. 

Eczema Manuum. Eczema of the hands has been 
called " washerwoman's itch," " grocer's itch," " brick- 



250 DISEASES OF THE SKIN. 

layer's itch," and various other itches. It is in many 
cases a trade eczema, caused by strong alkaline soaps, or 
contact with sugar, mortar, or other irritant, such as 
bichloride solutions, formalin, and the like. It may 
arise independently of any of these trade causes, or it 
may be part of a general eczema. The acute forms, as 
they occur upon the back of the hands, do not differ 
from the same on other parts of the body, and the same 
may be said of the chronic forms. The palms are seldom 
primarily affected, but secondarily to eczema of the 
wrists or fingers. The epidermis of the palms, as well 
as that of the palmar surfaces of the fingers, is thicker 
than that of the other parts of the body, excepting the 
soles of the feet, and so the vesicles do not rupture 
readily, but are seen like little, more or less translucent 
grains under the skin. When they rupture, the skin is 
left more or less ragged and worm-eaten. The skin over 
all the joints is liable to crack and form painful fissures. 
Chronic eczema of the palms prevents free movement 
of them on account of the thickening and the painful 
cracking. The skin is reddened and covered with large 
adherent scales. Itching is intense at times. The whole 
palm may be affected, or the disease may form limited 
areas, as upon the centre of the palm, over the thenar 
eminence, and upon the finger-ends. This form of 
eczema is often difficult of diagnosis from the squamous 
syphilide. The occurrence of the lesions upon one hand 
alone should arouse suspicion of syphilis, especially if 
little or no itching is complaned of. 

Treatment. Eczema of the palms is one of the 
most obstinate of eczemas to treat when of chronic form, 
and requires active stimulation by means of tar ; salicy- 
lic acid ; the soap and salve treatment ; rubbing in 5 
to 10 per cent, of the oleate of mercury ; or painting 
with caustic potash. The constant wearing of rubber 
gloves is excellent for the purpose of softening the skin 
and preparing it for other remedies. It is best to buy 
the canvas-lined gloves, turn them inside out, and wear 



ECZEMA. 251 

the rubber next the skin. The hands must be kept out 
of water. Where this cannot be done, great care must 
be used in drying them. It is well to have the patient 
dry on two towels or before the fire, and then either to 
thrust the hands in a box of cornstarch powder or flour, 
or preferably to apply the proper dressings. Eczema of 
the back of the hands is treated the same as an eczema 
elsewhere. Unna teaches that eczema of the hands and 
fingers is always secondary to eczema seborrhoicum 
capitis. He recommends in the disease, as it affects 
cooks, housemaids, and the like, that the hands, on 
going to bed, should be washed with green soap and 
water when the eczema is of squamous form, and with a 
weaker soap when it is moist. Then a paste of 



or one 



Oxide of zinc, 40 parts. 

Chalk ^ 

Lead- water, I 20 " 

Linseed oil, J 

of 



Oxide of zinc, -i 

Sulphur, | 

Chalk, \- aa 29 parts. 

Linseed oil, 

Lime-water, J 

is to be well rubbed in. Before using the paste, when 
the eczema is moist the patch should be powdered with 
flour. The paste is covered with the thinnest rubber 
tissue, such as is used for bouquet handles. This will 
stick well. Cotton gloves can be worn at night. In 
the morning the dressing is not to be removed until the 
roughest part of the work is done. Then it is to be 
washed off, and a little of the paste applied until time 
for the evening dressing. 

In eczema of the hands of masons, washerwomen, and 
the like, an endeavor must be made to thicken the 
corneous layer of the skin by dressing them at night 
with a paste of 



252 DISEASES OF THE SKIN. 



Resorcin, •» 

Ungt. zinci oxid., J 



aa 10 parts. 

Terse silicae, 2 " 

and applying oil or vaseline over it. In the morning the 
hands are not to be washed, but anointed with some oil. 
After a time the corneous layer thickens and the old skin 
falls off. Eczema of the hands due to occupation be- 
comes rapidly well when the patient no longer follows 
his trade. It is sometimes necessary to seek some other 
occupation. Hospital nurses are often much troubled in 
this way, and have to give up nursing. 

Eczema Narium is often, if not always, associated with 
a chronic rhinitis. It is very obstinate. Crusts form on 
the inside of the nose, are picked off, re-form, and after 
a time ulcers may result from the constant irritation. 
Sometimes in adults the disease locates itself about 
the hair follicles, and is very annoying. It is a not un- 
common point of departure for recurrent attacks of facial 
erysipelas. If long continued, it gives rise to a thicken- 
ing of the upper lip. Furuncles sometimes complicate 
matters. 

In the treatment of these cases the first attention must 
be given to the cure of the rhinitis. Then all crusts 
must be removed by soaking with oil. For the eczema 
we may use : 

]£ Glycerol, plumbi subacetat, ^ 

Ungt. aquas rosse, } aa p " *' M. 

as recommended by Hardaway. 

Herzog l recommends the yellow oxide of mercury 
ointment, or equal parts of ungt. plumbi and vaseline, 
spread on lint and accurately applied to the diseased part. 
Unna rolls his zinc and red precipitate ointment muslin 
into a pledget and introduces it into the nose. In ob- 
stinate cases about the hairs epilation by electrolysis may 
have to be performed. 

Eczema Palpebrarum is usually of an erythematous 

i Arch. f. Kinderheilkunde, 1887, p. 211. 



ECZEMA. 253 

character, and occurs as part of the same disease else- 
where. Eczema of the cilia, also called blepharitis cili- 
aris, is always pustular. The edges of the lids are swol- 
len, rounded, and more or less thickly strewn with pus- 
tules or crusts. The lids stick together on waking in 
the morning. In the squamous form the edges of the 
lids are merely red and scaly. It is almost always sym- 
metrical, occurs usually in strumous subjects, and is due 
to conjunctivitis. 

Treatment. The lids should be anointed before 
going to sleep, in order to prevent their sticking to- 
gether. I have always found the following ointment, as 
given by my friend, Prof. D. Webster, of the New York 
Polyclinic, most excellent : 

& Ac. salicylici, gr. x ; 75 

Ungt. hydrarg. oxid. rubra, gj j 4 

Ungt. aquae rosae, gvj ; ad 24 M. 

An ointment composed of 

U Hydrarg. oxid. flav., gr. ij-viij ; 0,13-5 

Vaselini, ^j ; ad 32 j M. 

is recommended by Hardaway. Resorcin, gr. iij in cold 
cream, Sijss, is editorially commended in the Monats- 
hefte f.pralct DermaL, 1888, vii., 1057. AVhatever is 
used, we must be sure that any substance entering into it 
is in an impalpable powder, so as to avoid the possibility 
of getting anything gritty into the eye. Epilation may 
be necessary in some cases. Solutions of bichloride of 
mercury (0.05 to 500) are commended, both for the con- 
junctivitis and the eczema dependent upon it. In any 
event, the conjunctivitis must be treated. 

Eczema Pedum. Eczema of the soles of the feet, though 
not so common as that of the palms, presents the same 
symptoms and calls for the same treatment. The greatest 
difficulty will be encountered in dressing the toes properly. 
For this the ointment should be spread upon a long and 
narrow strjp of lint, the centre of the strip placed agaiust 
the big toe, and the strip wound in and out between the 



254 DISEASES OF THE SKIN. 

toes. A piece of salve-muslin may be substituted for this 
with advantage. A piece of rubber sheeting cut to fit the 
sole and bound down with a bandage takes the place of 
the rubber glove. 

Eczema Unguium. Eczema may affect the nail-fold 
alone, and the nail may be scarcely diseased ; or the matrix 
and bed may be diseased, when the nail will lose its luster, 
and become rough, uneven, striated, and atrophied. Only 
one nail may be diseased, or all of them may be. The nail 
may be depressed in the centre and turned up at the end, 
with an accumulation of scales under its free border. 
Usually eczema of the nails occurs as a part of a general 
eczema, but it may occur as an independent disease. The 
fleshy parts about the nails usually present signs of inflam- 
mation, and often of an evident eczema. 

It is best treated by means of cots made of rubber It 
must be remembered that an ointment can never be used 
when rubber is, as the grease rots it. If the time has come 
for an ointment, linen or leather cots must be substituted 
for the rubber ones. The ointment to be used will depend 
upon the condition of the skin about the nails. Strapping 
the nails with a 10 per cent, salicylic acid plaster is often 
most satisfactory. 

Universal Eczema is uncommon, and when it does occur 
it is usually of the erythematous or squamous variety, 
with a tendency to cracking in the skin creases of the 
joints, exudation, scaling, and itching. These symptoms 
will serve to distinguish it from dermatitis exfoliativa, to 
which it bears a strong resemblance. Constitutional dis- 
turbances, such as fever and chills, loss of appetite, and 
digestive disorders, are not uncommon in these truly piti- 
able cases. Furunculosis is apt to complicate matters. 
The patients are slow in recovering, and are apt to be a 
good deal pulled down by the disease. 

Treatment. These patients should be put to bed and 
the underlying cause searched for, and if possible removed. 
They are best treated locally by lotions, oils, or vaseline. 
The ordinary Carron oil, equal parts of linseed oil and 



ECZEMA INFANTILE. 255 

lime-water ; cotton-seed oil with carbolic acid, 1 part of 
acid to 60 of oil; or simply smearing the body with 
vaseline and powdering on cornstarch, will each relieve. 
Salicylic acid in oil, 1 in 30, will also allay the discomfort, 
but it sometimes causes symptoms of constitutional pois- 
oning, and has to be stopped. Alkaline baths, warm, fol- 
lowed by one of the above, after tapping the skin gently 
dry, will also relieve, but the bath should not be used 
more than once a day. Its temperature should be about 
90° F. ; it should last ten or fifteen minutes. Bulkley 
recommends anointing the skin, before drying it, with — 

1£ Acid, carbolici. 9j-3ij j 1— 6i 

Glycerit. amyli, ad ,^iv; ad 100 M. 

applying it freely. The best way of drying the skin is 
to envelop the patient in a warm sheet, and pat the skin 
dry. As the intensity of the eczema lessens, the frequency 
of the baths must be reduced. The disease will gradually 
become localized in patches. 

Eczema Infantile presents certain peculiarities that Avar- 
rant its being considered as a special variety of eczema. 
It is very prone to be of the pustular form, following the 
rule that in delicate or debilitated subjects an eruption 
upon the skin is apt to be pustular. While in adults 
eczema of the face is usually erythematous, in infants it is 
nearly always pustular. In them it is quite common, if 
not the rule, to have several regions affected at once, such 
as the scalp, the face, and the region of the crotch. In 
them, also, eczema madidans often occurs in these regions. 
While in adults that form ot eczema is most frequently 
seen upon the legs, in infants it is quite exceptional there. 
Eczema of the scalp in infants presents itself as a thick 
crust formed of purulent matter, epithelial debris, and 
sebaceous matter. This is called "ruilk crust." When 
the crust is raised the scalp will be found to be thickened, 
swollen, boggy, and moist, with a purulent secretion. The 
whole scalp may be affected, or only the vertex. A\/ T ith it 
there will nearly always be a moist surface behind the 



256 DISEASES OF THE SKIN. 

ears, even though the face may be comparatively or abso- 
lutely free. The lymphatic glands will be swollen, but 
they seldom suppurate. When the face is affected it will 
sometimes be studded over with holes, superficial ulcera- 
tions, which, however, never leave scars. This appearance 
is seen very rarely in adults. It is often striking to note 
that the skin about the mouth and nose, and below the 
eyes, is in perfect health, though pale, while all the rest 
of the face may be involved in the moist intense inflamma- 
tion. The creases of the neck, the flexures of the joints, 
and the region of the genitals usually show an erythematous 
or a moist intertriginous eczema. At times the whole 
body will be affected with a general, but very rarely with 
a universal eczema. While the pustular and intertriginous 
forms of eczema are the most common, we may have all 
forms present at one time. The papular form is also fre- 
quently met with alone. Itching is usually severe, keep- 
ing the little patient awake at night, and the tearing made 
by the nails to relieve the itching gives rise to immense 
excoriations, especially of the face. Unrelieved, the little 
patients sometimes become pitiable objects on account of 
loss of sleep and constant nervous excitement. 

Etiology. There are several causes tending to pro- 
duce eczema in infants. Their skin is vulnerable to all 
irritants. When we consider that the child is born into 
the cold world, suddenly launched out of a warm atmos- 
phere in which it was surrounded by an alkaline fluid, 
covered over with a fatty coating, and safe from the action 
of the atmospheric air, we can but wonder that its skin es- 
capes as well as it does. More than one-third of the cases 
of eczema occurring before the fifth year of life occur in the 
first year. Add to the vulnerability of the skin the over- 
zealous care as to cleanliness commonly bestowed upon it 
for a few months after birth, and we have a good explana- 
tion for its frequence. Bad diet has much to do with its 
production. The vast majority of the little sufferers. are 
nursed too often if at the breast, " every time they cry" 
being the rule; or fed too frequently or improperly, 



ECZEMA INFANTILE. 257 

" everything that is going" being again the rule. Inatten- 
tion to the condition of the diapers is another active cause 
of eczema about the genitals. Teething is, without doubt, 
an exciting cause, a fresh outbreak of eczema marking 
the eruption of each , tooth. Want of self-control in 
scratching is an aggravating circumstance. The frequent 
disturbances of digestion so common at this period of life 
predispose the infant's skin to eczema with rather more 
force than do the same troubles in adults. Fat babies are 
frequent subjects of eczema, especially of the intertri- 
ginous variety. 

Treatment. The treatment of eczema infantile is 
along the same lines as that of eczema in adults. Special 
stress must be laid upon the feeding of infants, and strict 
rules must be laid down for the parent's guidance. The 
condition of the breast milk must be inquired into, as it 
is often of too poor quality to nourish the child. Women 
will sometimes nurse their children far too long, with the 
idea of preventing conception. If the child is bottle-fed, 
the quality of the milk must be investigated, and it as 
well as the amount regulated. It is very necessary to 
insist upon the child wearing a mask in eczema of the 
face and scalp. This may be made of light flannel or 
muslin, a piece of the stuff being cut somewhat after the 
shape of the face, with holes cut out for the nose, eyes, and 
mouth. A skull cap is to be made, onto which the mask 
may be sewed, or pinned with safety-pins. The ointment 
is to be spread upon lint, cheesecloth, or washed muslin 
— a strip for the forehead, one for the chin, and one for 
each cheek. These are to be laid upon the face, and then 
the mask put over them, fastened to the skullcap, and tied 
behind the head by two strings from its lower corners. It 
is astonishing what relief this affords to the itching, and 
how much more rapidly the case improves under it. As 
it is impracticable to use the mask in public practice, 
Unna's paste made of 
17 



258 DISEASES OF THE SKIN. 



ft Oxide of zinc, 40 parts. 

Chalk, 

Lead water, \- aa 20 " M. 

Linseed oil, 



may be used as a substitute. In making, the first two 
ingredients are to be mixed together, and then the last two, 
and then the two parts thus formed. It is to be painted 
on the part, and can not be readily rubbed off 1 , though it 
can be washed off with a little oil. 

The itching of the skin can be relieved by appropriate 
dressings, and it is never necessary to put the child in a 
home-made straight-jacket, by slipping it into a pillow- 
case and sewing up the same between the arms and body. 
This is an extreme measure. In eczema of the crotch 
great care must be given to changing the napkins as soon 
as soiled. Fresh, clean ones must be put on, not those 
that have been dried without being washed. Dr. George 
H. Fox has called attention to a tight prepuce as the cause 
of eczema in male children. The urine dribbles away, so 
that a few drops wet the clean diapers, and thus keep up 
the trouble. In such cases judicious stretching of the 
prepuce may obviate the necessity for circumcision. Water 
must be kept from the skin in all acute cases. 

Internally, calomel in tablet triturates, T \ grain, three 
times a day for three days, will give good results in 
many cases, even though the bowels are not constipated. 
After an interval of three days the calomel is to be given 
again. Care must be taken not to produce too frequent 
and loose movements of the bowels. The rhubarb and 
soda mixture is excellent in many cases. Other medica- 
tion will be necessary according to the nature of the case. 
Cod-liver oil will often cure a case which has been very 
obstinate. The local treatment is, according to the rules, 
already given under Eczema. 

Eczema Exfoliativum. See Dermatitis exfoliativa. 

Eczema Marginatum. See Trichophytosis. 

Eczema Seborrhoicum. See Dermatitis seborrhoica. 



ELEPHANTIASIS. 



259 



Elephantiasis. Synonyms : Barbadoes leg ; Coch in- 
China leg ; Glandular disease of Barbadoes ; Sarcocele of 
the Egyptians ; Tropical big-leg ; Bucnemia tropica ; 
Morbus elephas ; Pachydermia ; Spargosis ; Phlegmasia 



Fig. 28. 




Elephantiasis. (After Taylor.) 

Malabarica ; Hernia carnosa ; Elephantiasis Indica seu 
Arabum. 

A chronic endemic or sporadic disease of the skin, 
characterized by hyperplasia of the skin and subcutane- 
ous tissues, due to a stoppage of the lymphatic or venous 
circulation, especially the former, affecting chiefly the 
lower extremities, and marked by enormous enlargement 
of the affected part. 



260 DISEASES OF THE SKIN. 

Symptoms. In certain tropical regions, such as India, 
China, Japan, Egypt, Arabia, the West Indies, and South 
America, the disease is endemic ; but sporadic cases occur 
in all parts of the world. The symptoms of the two 
forms differ only in that in the endemic variety there is 
usually what is called '- elephantoid fever," with lumbar 
pain, nausea, and vomiting, and followed by sweating. 
The fever is of high grade, and bears a striking resemb- 
lance to malarial pyrexia. In sporadic cases the char- 
acteristic fever is wanting, though usually there is some 
constitutional disturbance preceding the local symptoms. 
In other instances the fever is altogether wanting. 

Locally the affected part at first is attacked apparently 
by erysipelas, or a deep dermatitis, phlebitis, or lymphan- 
gitis ; it becomes greatly reddened and swollen ; and there 
may or may not be a clear or milky discharge from the 
skin, and an eruption of vesicles. After a time these 
symptoms subside, but the part does not return to its 
normal size, and there is some pittiog of the skin on 
pressure. After a few weeks or months there is a repe- 
tition of the attack, and the part is left still more enlarged. 
And so the case progresses with varying periods of quies- 
cence, and recurrent erysipelatous attacks, each one leaving 
the part more thickened than before, until it attains enor- 
mous proportions. The normal contour of the part is lost ; 
the folds of the skin are obliterated, the surface is smooth 
and shiny, and the color grows darker, even blackish. 
Now no impression can be made upon the swelling by 
pressure of the finger. Ulcerations are apt to occur, and 
some cases show varicose lymphatics which are tender aud 
painful, and may rupture of themselves or by accident 
and discharge a clear or milky chylous, coagulable fluid. 
The escape of this fluid saps the patient's strength. 

The parts most frequently affected are the legs, usually 
one, but may be both ; and next to them, the male or 
female genitals. It occurs also on the arms, face, ears, 
female breast, and tongue. When the leg is the seat of 
the disease it becomes so large as to interfere with locomo- 



ELEPHANTIASIS. 261 

tion and compels the sufferer to take to his bed. The 
surface of the limb may be smooth ; or uneven on account 
of the varicose lymphatics ; or warty on account of en- 
largement of the papillae. The foot and leg may melt into 
each other, as it were, all trace of the ankle being lost. 
Wherever there are two surfaces in contact there is apt to 
be a decomposition of the sweat, sebaceous matter, and 
epithelium, giving rise to a foul odor, like, but worse than, 
that of an ordinary intertrigo. The lymphatic glands in 
the groin are enlarged. Eczema may develop with its 
attendant itching. The appearance of this elephantine 
leg gave the name to the disease. When the scrotum is 
the affected part, vomiting often occurs in the febrile at- 
tacks, as well as pain in the groins, along the spermatic 
cord, and in the testicles. Hydrocele may develop, and 
the abdominal rings, overstretched by the swollen cords, 
may give opportunity to the formation of hernia upon the 
subsidence of the acute symptoms. The scrotum may 
become so large as to reach the ground when the patient 
is standing, and one case has been reported in which it 
weighed one hundred and ten pounds. One form of the 
affection is called "lymph scrotum or nsevoid elephanti- 
asis," on account of the marked dilatation of the lym- 
phatics. 

There are all degrees of thickening of the skin and 
subcutaneous tissues, but the recurrent attacks of erysipe- 
las and the progressive enlargement are characteristic of 
all. The bones may become enlarged. This is a very 
rare affection, which is called "acromegalia." In the 
Lancet of June 11, 1887, several cases are reported, one 
of which was on exhibition in a travelling show as the 
"Elephant man." In his case the head attained massive 
proportions. 

Etiology. The disease occurs in both sexes and in all 
ages, but is most common in men of middle life and in 
the dark-skinned races. Moncorvo 1 reports a case in an 

1 Rev. mens, des Mai. de l'Enfance, 1886, iv., 101. 



262 DISEASES OF THE SKIN. 

infant four months old, and speaks of a case in one fifteen 
days old. He believes that it may develop in utero. 
Floras 1 reports a case beginning at birth and remaining 
stationary for fifteen years, when it assumed the typical 
course of the disease. It is particularly prevalent in damp, 
malarious parts of the seacoast, and the mosquito is sup- 
posed to be the carrier of the infection. It is not sup- 
posed to be hereditary, though in countries in Avhich it is 
endemic several members of the same family may be affect- 
ed by it. Leprosy and elephantiasis have been accident- 
ally associated. Exposure to cold, phlegmasia dolens, 
cellulitis, ulcers, lupus, repeated attacks of eczema or 
erysipelas, posture, as the hanging down of a limb on 
account of rheumatism, pressure upon veins or lymphat- 
ics by tumors, may give rise to the disease. In fact, any 
disease of the skin that is attended by repeated inflam- 
matory outbreaks favors the occurrence of elephantiasis. 
The filaria sanguinis hominis is said to be the cause of 
the endemic form of the disease. It is not found in every 
case, and is rarely encountered in sporadic cases. 

Pathology. Anything that will occlude the lym- 
phatic or venous channels may cause the disease In en- 
demic cases it is the adult filarise that do this. In spor- 
adic cases the several etiological factors play the same part. 
However caused, the result is an enormous hypertrophy 
of the subcutaneous tissue from increase of fibrous tissue 
in various stages of development. The corium is also in- 
creased in thickness, and there is proliferation of the 
epidermis, enlargement of bloodvessels, lymphatics, and 
nerves. In advanced cases the muscles undergo fibro- 
fatty changes, and the bones become enlarged. (Crocker.) 

Diagnosis. The recognition of elephantiasis is easy, 
as its symptoms are pronounced. In some cases of 
syphilis, however, an elephantiasic thickening of the foot 
or feet takes place that may be thought to be elephan- 
tiasis. In it, however, there is an absence of the history 

i Arch. f. klin. Chirurgie, 1888,xxxvii., 598. 



ELEPHANTIASIS. 263 

of repeated inflammatory attacks, the outline of the 
thickening is rather well defined, and old cicatrices or 
ulcers characteristic of syphilis will commonly be found. 
The condition is one of gummatous infiltration with 
chronic oedema, consequent upon obstruction of the 
lymphatics. 

Treatment. The best thing for a patient with en- 
demic elephantiasis to do is to go to a more healthful 
climate. The treatment of the patient during the ex- 
acerbations is purely symptomatic, with fomentations, 
quinine, iron, and the like. Various measures for the 
cure of the disease have been proposed, but none is per- 
fectly satisfactory. Of course, the scrotal tumor may be 
cut off. The leg has been amputated at the hip, a dan- 
gerous operation. Unfortunately, the other leg has be- 
come diseased soon after the one has been cut off. Liga- 
tion of the femoral artery has been performed, but the 
result has not been satisfactory. Compression by means 
of a Martin's rubber bandage, or the ordinary roller 
bandage, will afford relief. When it is left off for a time 
enlargement will again take place. It, of course, cannot 
be used while inflammation is present. Bentley * has re- 
ported the cure of a case by the inunction of a J drachm 
of mercurial ointment twice daily, and the applica- 
tion of a firm bandage for fourteen days. After that 
the inunctions were made once a day. Internally he 
gave iodide of potash alone, or in this formula : 

R 



M. 



Galvanism has produced alleviation, if not cure, in 
some cases. Pusey quotes a case cured by a>rays by 
Mascat. 2 Hardaway has seen great amelioration in one 
case by the use of Squire's glycerole of the subacetate of 

i Lancet, 1878, i., 785. 
2 Lancet, 1898, i., 544. 



Potass, iodid., 


By ; 


2 


Potass, chlor., 


3j; 


4 


Sol. hydrarg. perchlor., 


3 ss ; 


16 


Inf. chiretta, 


ad 5viij; 


ad 250 


^ss t. i. d. 







264 DISEASES OF THE SKIN. 

lead. Massage is beneficial. Stretching or excision of 
a part of the sciatic nerve is spoken of by J. Nevins 
Hyde as having been followed by amelioration of the 
condition. 

Prognosis. Unless the patient is exhausted by the 
loss of lymph, the disease may last indefinitely without 
deterioration of the health. Death may result from 
pyaemia or thrombosis. The patient often dies from some 
intercurrent affection. 

Elephantiasis Graecorum. See Leprosy. 

Emphysema of the skin is a rare accident. It usually 
affects the upper chest and neck, and is due to a rupture 
of the pulmonary alveoli on account of vomiting or par- 
oxysmal coughing, and the air making its way under the 
skin. The affected part looks swollen, feels cushiony, 
and gives a delicate crackling sound on palpation. There 
will be a history of the sudden occurrence of the swell- 
ing after coughing or vomiting, and probably more or 
less dyspnoea will be experienced. The air slowly 
escapes and the parts return to their normal condition. 

Endemic Verrugas. See Favus. 

Endothelioma. Under this title E. Spiegler 1 and 
others has reported several cases of tumors that occurred 
in adult life, upon the scalp especially, but also on other 
regions. They were present in great numbers and tended 
constantly to increase in number and in size. They 
varied in size from a pea to an orange. They projected 
high above the level of the skin, and were round or flat- 
tened. They were firm and elastic, and were either cov- 
ered with smooth adherent skin or superficially excori- 
ated or ulcerated. The apposed surfaces of neighboring 
tumors were often deprived of epidermis, bled slightly, 
and secreted a sero-purulent, badly smelling fluid, which 
dried into crusts between the tumors. In one of the 
cases the disease had lasted forty years, and there was a 

1 Arch. f. Dermat. u. Syph., 1899, 1., 163. 



END UBCISSEMENT D U TISS U CELL ULAIRE. 265 

history of the first tumor having appeared after the heal- 
ing of a cut of the scalp. Endotheliomas may occur else- 
where than on the scalp. Gottheil l reported one on the 
foot. It was a black tumor, irregular in shape, rounded, 
sharply defined, slightly elevated; and smooth, excepting 

Fig 29. 




Endothelioma. (Spiegler.) 

for two or three small orifices from which blood serum 
exuded. It was cut out and returned. The diagnosis 
of these tumors can not be made with certainty without 
the aid of the microscope. These tumors originate in 
the endothelium lining the lymphatics or bloodvessels. 

Endurcissement du Tissu Cellulaire. See Sclerema neo- 
natorum. 

1 Jour. Am. Med. Assn., 1907, xlvii, 93. 



266 DISEASES OF THE SKIN. 

Engelures. See Dermatitis calorica. 
Ephelides. See Lentigo. 
Ephidrosis. See Hyperidrosis. 
Ephidrosis Cruenta. See Hsematidrosis. 
Ephidrosis Tincta. See Chromidrosis. 

Epidemic Skin Disease of Savill. See Dermatitis epi- 
demica. 

Epidermolysis Bullosa. Synonyms : Acantholysis bul- 
losa (Goldscheider and Joseph); Dermatitis bullosa 
(Valentine). This is a rare disease, or rather peculiarity 
of the skin, in which bullae arise upon the slightest 
pressure. The disease usually first appears in infancy, 
but may do so later in life, and occurs especially upon 
the hands and feet, but may occur anywhere on the body, 
cases having been reported as occurring in the mouth. 
The tendency to the formation of bulla3 lessens toward 
middle life. The lesions begin either as red spots, which 
are itchy, or without precedent redness or other subjective 
symptoms. A bulla begins to form shortly after the 
exciting pressure, such as from the shoe in walking, or 
even friction from a suspender, has been received, and 
keeps on enlarging for two or three days. It then grad- 
ually decreases, dries into a crust, which falls, leaving 
healthy skin. If the bulla is broken, it discharges a 
yellow, slightly sticky fluid, and leaves a suppurating 
base. It may be hemorrhagic. The disease is heredi- 
tary in certain families, but it may occur independently 
of this. It is most pronounced in summer-time. In 
most cases there is hyperidrosis. 

Pathology. Elliot, 1 from his microscopical study of 
the disease, believed it to be " due in a predisposed indi- 
vidual to an excessive response on the part of the blood- 
vessels to an external irritation, and the consequent pour- 
ing out of an enormous amount of serous exudation." He 
regarded it as an " inflammatory process, originating in 
the cutis itself, and manifesting itself by the formation of 

1 Journ. Cutan. and Gen.-Urin. Dis., 1895, xiii., p. 10. 



EPITHELIOMA. 267 

bullae after slight or severe traumatisms." J. Bukovsky 1 
fouud uo change in the unaffected skin, and believed that 
it is dependent upon some physical defect, such as an 
inequality of contractility of the skin. Engman in one 
case found an absence of elastic tissue from the skin. 
Treatment. No treatment is of avail. 

Epithelialkrebs. See Epithelioma. 

Epithelioma. Synonyms : (Fr.) Epitheliome cancroi'de ; 
(Ger.) Epithelialkrebs ; Cancroid, Skin cancer, Epithelial 
cancer, Noli me tangere, Rodent ulcer. 

Epithelioma is a chronic, progressive, malignant new 
growth in the skin or mucous membrane, which is char- 
acterized by the formation of ulcers with raised, hard, 
waxy edges, and by a strong tendency to return after 
apparent removal by knife or caustic. 

Symptoms. Epithelioma always begins in a most 
innocent manner, and may be present for months or years 
before the patient dreams that he has a serious disease. 
It may occur upon the skin alone, or upon the mucous 
membrane alone, or upon both the skin and mucous 
membrane at their line of juncture. Epitheliomas oc- 
curring upon the tongue, larynx, or uterus do not con- 
cern us here, as they belong to the domain of surgery. 
The starting-point of the disease may be a crack or an 
abraded scaly spot, as on the lip ; a small, flat, scaly 
sebaceous patch ; a white, pearly looking, hard nodule ; 
a senile or other wart or papilloma ; a pigmentary mole ; 
a cicatrix ; an adenoma ; a chronic or lupous ulcer ; a 
psoriatic patch, or some other new growth in the skin. 
Some of these lesions may have been present for many 
years, as, for instance, a mole. Some appear but a short 
time before they frankly declare their nature, such as 
the waxy nodule. However it may begin, it will be 
noted that the previously existing lesion more or less 
rapidly becomes more dense, and after a varying time 
ulceration occurs, the disease spreads at its edges, and 

Archiv Dermat, u. Syph., 1903, bfvii, 163. 



268 DISEASES OF THE SKIN. 

the ulceration grows deeper and deeper, eating its way 
through skin, muscles, and bone in the infiltrating form, 
or creeping over the surface in the most superficial form. 
The lymphatic glands may be involved early in the 
course of the disease in the deep forms, or not for many 
years in the superficial forms. Eventually they may be- 
come swollen, hard, break down, and ulcerate, assuming 
the appearance of an epitheliomatous ulcer. A typical 
epitheliomatous ulcer is irregular in shape, with raised, 
hard, waxy-looking, rounded, or everted edges, over 
which, quite commonly, course dilated bloodvessels ; the 
floor is uneven, bleeds easily when touched and is cov- 

Fig. 30. 



& 




Epithelioma. 
(From Prof. G. H. Fox's service at the Vanderbilt Clinic.) 

ered by a brownish crust or a sanious, purulent secre- 
tion. Epitheliomas are usually single lesions, but they 
may be multiple. Sometimes a single epithelioma attains 
vast dimensions, involving the whole of one side of the 
face, scalp, and neck in one huge excavated ulcer. Some- 
times before the characteristic ulceration develops the 
new growth may take the form of a single enlarged papilla 
or a group of them. In some cases it may have a cauli- 
flower-like appearance, spreading out from a more or 
less narrow base. Fissures are apt to form between the 
papillae, and then there is usually an offensive discharge. 
This is called the papillary form. 

Subjective symptoms are absent in many cases at first, 



EPITHELIOMA. 269 

but in the deep, infiltrating form pain of a lancinating 
character is present. This often is so severe that the 
sufferer is robbed of his sleep. In the small and more 
superficial cancers there commonly is no pain, and the 
patient experieuces only the discomfort incident to the 
ulceration. If the ulcer extends and goes deep so as to 
implicate nerves in nearly all cases lancinating pain is a 
symptom of the disease. 

The course of the disease is always chronic. Different 
cases show different stages of malignancy. Some will 
prove fatal in four years or less ; some will last indefi- 
nitely. There is no tendency to recovery, though at 
times a partial attempt at healing will be made. Super- 
ficial epitheliomas may creep over the skiu, healing up in 
the older parts while spreading outward. While all epi- 
theliomas show a strong tendency to return after opera- 
tion and in the scar left by it, in some cases this ten- 
dency is much more marked than in others. 

While epithelioma may occur upon any part of the 
body, it is most frequently located upon the lower lip, 
where it occurs, according to Paget, in 50 per cent, of 
the cases. It is very common for it to begin as a crack 
in the vermilion border, which does not heal. The 
neighboring lymphatic glands are involved early in this 
form. The next most common location is the face. A 
favorite location upon the face is upon the side of the 
nose and near the inner can thus of the eye. Here it is 
very apt to pass over onto the eyelid and destroy it. 
Not infrequently it begins upon the eyelid itself. The 
external genital organs of both sexes, and the anal region 
more rarely, are other common sites. The upper lip is 
very rarely affected. 

It is customary to describe a number of forms of epi- 
thelioma, but it seems to me much better, especially for 
a student, not to encumber his mind with too many 
names. The superficial, deep-seated or infiltrated, and 
the papillary forms have already been mentioned. The 
chimney sweep's cancer is an epithelioma of the scrotum 



270 DISEASES OF THE SKIN. 

met with in paraffin-workers and chimney-sweeps. The 
rodent ulcer used to be described as a special form of dis- 
ease, and still is so by English surgeons. Clinically, it 
is supposed to be characterized by occurring on the skin 
of the upper half of the face, by running a slow and 
painless course, by not involving the lymphatics, and by 
lateral rather than perpendicular extension. 

Etiology. The cause of epithelioma is often ob- 
scure. We know that repeated irritation of a part is 
often followed by its advent. Smoking short clay pipes 
is not uncommonly followed by epithelioma of the lip ; 
a ragged tooth accounts for many an epithelioma of the 
tongue ; the wearing of spectacles or eye-glasses has in 
some cases apparently caused the new growth upon the 
nose ; constant picking or inadequate attempts at the re- 
moval of warts and scaly spots would seem to account for 
some epitheliomas of the face ; and the scratching to relieve 
pruritus of the anus may play the same part in produc- 
ing the disease about the anus. This constant irritation 
would explain the appearance of epithelioma in paraffin- 
workers and chimney-sweeps, in chronic ulcers, psoriasis, 
old cicatrices, and the like. J. N. Hyde, 1 sees in the 
action of the sun's rays a possible cause, and draws at- 
tention to the fact that the face and hands are the com- 
mon sites of the disease. Further, it is more common 
in men than in women ; in farmers than those living in 
cities; and rare in negroes who are protected by an 
abundant pigment. Xeroderma pigmentosum, caused 
by the action of sunlight, has epithelioma as a common 
sequence. A congenital or acquired phimosis and the re- 
peated inflammation due to decomposing smegma are 
forerunners of the disease upon the penis. Age is the 
most pronounced predisposing cause. The disease is rare 
under thirty years of age, and increases in frequency 
beyond that period. One case has been reported by 
Kaposi in the tenth year of life. Heredity has some in- 

1 Amer. Jour. Med. Sciences, 1906. 



EPITHELIOMA. 271 

fluence, though D. Lewis has found that it is not so well 
marked as it is frequently assumed to be. Males are 
more often affected than females. It seems to have a 
predilection for all neoplastic growths. The theory that 
it is due to a specific parasite, and therefore contagious, 
thus far has not been demonstrated. 

Pathology. Epitheliomas take their origin from the 
cells of the skin appendages, hair follicles, sweat or seba- 
ceous glands, from misplaced embryological epithelium, 
or, by far most frequently, from the rete Malpighii. 
Histologically, the tumors are most conveniently con- 
sidered in two classes which are morphologically quite 
distinct. The difference between the two depends not 
so much upon the point of origin of the growth, as upon 
the tendency of the tumor cells, in the one instance to con- 
tinue a process of specialization, similar to the normal 
development of the cells from the stratum mucosum to 
the stratum cornum, or, in the other, to revert to a more 
primitive and embryological type. Tumors of the lat- 
ter class are known as basal celled epitheliomas. 

In both forms the essence of the process is a proli- 
feration of epithelial cells of varying size and shape. 
The resulting cell masses penetrate the corium and often 
fuse with the formation of alveolar structures, the trabe- 
cules of which, on section, show dendritic branching. 
Proliferating epithelial nipples project into connective 
tissue, which, as far as amount and density are con- 
cerned, varies greatly, but is always very cellular, rich 
especially in plasma and giant cells and mononuclear 
leucocytes. 

In the first-class the epithelial cells have in a measure 
the life history of normal epithelium, but as they are no 
longer growing on a free surface, but in enclosed spaces, 
they become packed in masses, the older cells being 
forced toward the centres so that at length there are 
formed concentrically arranged cell masses, which, when 
cut across present the dense white lamellated rounded 
structures which have been called epithelial pearls. Such 



272 DISEASES OF THE SKIN. 

pearls are rarely found in other conditions, although they 
may be present whenever any lesion involves the growth 
of epithelium into a limited space. In doubtful cases 
their occurrence with other marks of cornification and 
the presence of intercellular bridges may be of great 
diagnostic importance. There is variation in the degree 
and depth to which the corium is invaded. In rodent 
ulcers the tendency of the growth is to remain near the 
surface, proliferation and metamorphosis are sIoav, and 
necrosis and cicatrization extend pari passu with the 
lateral growth of the tumor. In larger tumors ulcera- 
tion takes place at the centre, while the edges become 
elevated by the papillary hyperplasia, extension of the 
tumor beneath the skin, and the inflammatory infiltra- 
tion. Before ulceration the tumor may project above the 
skin forming a wart-like or papillomatous growth. 

In the second group the tumor cells resemble those of 
the rete mucosum, or of certain glands, but in their retro- 
grade metamorphosis take on the appearance of connec- 
tive tissue cells, so that at times the tumor merges into 
the stroma with no sharp line of demarcation. The 
proliferating cells may form solid masses of various 
shapes, and sometimes gland-like or cystic structures. 
Different forms of degeneration of the stroma contribute 
along with the metaplasia and appearance of embryonal 
characteristics, to the formation of a very complex struc- 
ture. In this class are to be included many tumors 
which have been described as endothelioma, cylindroma, 
plexiform sarcoma and myosarcoma. 

Diagnosis. The disease must be differentiated from 
lupus, syphilis, sarcoma, papilloma, and seborrheal 
warts. From lupus it differs in an entire absence of 
brownish lupus tubercles ; in beginning late in life, as a 
rule, while lupus begins in early life ; by its compara- 
tively more rapid course ; its lancinating pain ; the in- 
volvement of the lymphatic glands ; the deep ulceration ; 
the waxy, raised, hard margin ; and the development of 
the cancerous cachexia. From syphilis it differs in hav- 



EPITHELIOMA. 273 

ing a single and not a multiple lesion ; in its slower 
course ; in its showing no tendency to recovery ; in its 
not responding to internal treatment ; in its painfulness ; 
and in its waxy, raised, hard margin. An initial lesion 
of syphilis on the lip has not infrequently been taken for 
an epithelioma. In it we have more rapid growth, more 
induration, an early enlargement of the neighboring lym- 
phatic glands of peculiar hardness, and the appearance 
of secondary eruptions on the body, all of which are 
wanting in an epithelioma. Sarcoma usually occurs 
earlier in life, tends to more rapid development with 
metastases in neighboring or distant parts, and either 
does not ulcerate or ulcerates in a very different way 
than does epithelioma. From papilloma and seborrheal 
warts there are no positive diagnostic marks of distinc- 
tion. Either of the two diseases appearing late in life or 
showing symptoms of activity at that time should rouse 
our suspicions. 

Treatment. Complete and radical destruction of 
the disease is the only thing to be done in the treatment 
of epithelioma. As a prophylactic measure, it is well to 
destroy all suspicious warts appearing after middle life, 
and to apply appropriate treatment to seborrheal patches 
occurring at the same period. Superficial caustics should 
never be used to an epithelioma, as they only encourage 
its growth. The radical treatment will differ with the 
point of view, all surgeons inclining to the knife, while 
dermatologists advocate the curette or powerfully destruc- 
tive caustics. If the knife is used, it must cut out a 
wide margin beyond the growth. Extirpation is espe- 
cially applicable, and the most appropriate treatment for 
epithelioma of the lip, eyelids, and penis. In the latter 
the organ must be amputated above the ulcer, if that has 
attained any size, and the inguinal glands likewise taken 
out. In all cases in which the lymphatic glands have 
become involved they should be taken out. Therefore 
when the lymphatic glands are involved only excision 13 
to be thought of. 
18 



274 DISEASES OF THE SKIN. 

To all superficial epitheliomas and to many of the infil- 
trating variety, Schwinimer's plan of treatment will be 
applicable, and will prove curative. The growth is to be 
scraped out thoroughly with the dermal curette (Fig. 31), 
and its base bored into with a stick of nitrate of silver 
or with the dental burr dipped in pure carbolic acid, as 
is done by G. H. Fox ; the diseased tissues will give way 
readily ; the bleeding is to be stopped by pressure ; and a 
pyrogattic acid ointment of 33 J- per cent, strength is to be 
applied. Care should be taken that it be applied exactly 
to the growth, for though it exerts its greatest action upon 
the diseased tissues, it also acts upon the sound skin. This 
ointment will produce a black crust over the growth, on 

Fig. 31. 




The dermal curette. 

account of oxidation of the acid, and will cause a free 
discharge from the scraped surface during a few days. 
The discharge becomes less by degrees. After a week or 
ten days the black crust is to be removed by covering it 
with carbolized vaseline for twenty-four or forty-eight 
hours. Last of all, mercurial plaster is to be applied, 
under which the part will heal. This method gives most 
satisfactory results, and is not particularly painful if 
cocaine is used hypodermically before the scraping. 
Smaller epitheliomata can be curetted without using co- 
caine. After curetting, the base should be bored into 
with a point of nitrate of silver. 

Arsenic holds the first place among caustics, Marsden's 
paste, composed of 1 or 2 parts of arsenious acid and 
1 part of gum acacia, by weight, rubbed together and 



EPITHELIOMA. 275 

mixed with a 20 to 40 per cent, aqueous solution of co- 
caine into a paste of the consistency of butter just before 
using, is perhaps the most often used. It is dreadfully 
painful and often causes great oedema. If orthoform is 
substituted for J to f of the gum acacia, the paste is 
hardly at all painful. Before applying an arsenical 
paste, if ulceration has not taken place, the epithelium 
should be curetted so as to leave a raw surface. It should 
be applied to the affected part on linen, the paste overlap- 
ping the edge of the tumor by half an inch, and left on 
for twelve to twenty-four hours, according to the patient's 
endurance and the effect produced. The patient should 
be seen frequently, and the paste removed as soon as a 
greenish or blackish eschar is formed. Carbolated vase- 
line is to be applied after the paste, and kept on continu- 
ously till the slough separates, and then simple ointment 
used. The slough may not fall for weeks, and when it 
does a clean surface is exposed that soon completely heals. 
It is to be noted that the use of a strong arsenical paste 
is much safer than a weak application, as it produces so 
much inflammation and destruction of tissue that the 
arsenic is not absorbed. Arsenic is better than some other 
caustics, as it attacks by preference diseased cells and leaves 
the sound skin almost unharmed. If the growth has not 
been destroyed, the process may be repeated. This is the 
treatment recommended by A. R. Robinson. 1 D. Lewis 2 
lias had good results from using Bougard's paste, as fol- 
lows : 



Wheat flour, > 
Starch, i 








aa60 


Arsenic, 








1 


Cinnabar, ) 
Sal. ammoniac, ) 








aa 5 










Corrosive sublimate, 










Solution of chloride of 


zinc 


@ 


52°, 


245 



50 

M. 



The first six ingredients are separately ground to a fine 

1 Atlantic Med. and Surg. Journ., 1895-6, xii., 713. 

2 Journ. Cutan. and Gen.-Urin. Dis., 1890, viii., 70. 



276 DISEASES OF THE SKIN. 

powder and mixed in a mortar. Then the solution of 
zinc is slowly added while the mass is stirred. It is to be 
kept covered in an earthen jar. A portion is to be applied 
accurately to the part and kept on for thirty hours, and 
followed by a poultice. Cocaine, 20 per cent., may be 
added to decrease the pain. Another method of using 
arsenic is known as Cerny's. He uses : 

R Acid, arsenios. pulv., 1 

Alcohol, ethyl, absolut., I ^ p. ». ad 150 

Aquae destillat, } 

The solution is to be shaken up and painted over the 
denuded surface of the epithelium, and a new coat laid 
on when the first is dry. It is used daily unless oedema 
is caused, Avhen a pause is made until this subsides. After 
a time an eschar forms and falls. The solution is then 
applied again to the surface, and if only a yellowish crust 
forms that can be removed without bleeding a cure has 
been effected. If a dark adherent crust forms, repeat as 
before. Healing at last is effected under 10 per cent, 
boric acid in vaseline. 

Lactic acid is another powerful caustic, to be applied 
by mixing it with an equal part of finely powdered silica 
and spreading it upon gum-paper. It is kept on for 
twelve hours, and renewed twenty-four hours afterward. 
Hardaway prefers to apply the syrupy acid by means of 
absorbent cotton for ten or fifteen minutes, and then wash 
off the excess of acid with water. This is done daily. 
Caustic potash and chloride of zinc in crayon is recom- 
mended by A. R. Robinson for epithelioma of the lip and 
small epitheliomas about the eyelids. The first is a con- 
venient agent in the form of potassa fusa. It is well to 
curette away the surface, and then to hold the potash 
stick against the wound for a few moments until the tis- 
sues liquefy. The application of dilute acetic acid will 
check the action of the potash. A raised scar sometimes 
follows its use. It will flatten in time. 

The thermo- and gsilvano-cautery may also be used. 
Resorcin has its advocates, as have chloride of zinc and 



EPITHELIOMA. 277 

the nitrate of silver. These may be of service where, for 
any reason, a more radical operation is not admissible. 
Fuchsine and methyl-blue, either injected under the skin 
or locally applied, will sometimes seem to stay the progress 
of an epithelioma, but will not cure it. 

During the past few years many cures of epithelioma 
by x-rays have been reported, and during the past few 
months radium has healed not a few. There is no ques- 
tion about arrays causing ulcerations to heal, but the time 
taken to effect a cure is much longer than that required 
by arsenic or caustic potash. In their favor is painlessness. 
They are also of great service in giving comfort to the pa- 
tient in inoperable cases. The x-rays are specially indicated 
in superficial and in inoperable cases. A medium hard tube 
should be used, exposures should be made every other day, 
the patient should be from four to ten inches distant from 
the target, and the duration of each sitting should be from 
three to ten minutes. The surrounding parts should be 
protected by sheet lead in which a hole is cut a little 
larger than the size of the cancer. The hard edges 
should be removed by curettage. It may take six to ten 
weeks to eifect a cure. This is often effected without the 
production of erythema. Treatment should be suspended 
when reaction appears. It should not be resumed under 
three weeks. 

Prognosis. The prognosis of epithelioma as to life is 
fairly good in cases in which only the skin is involved. 
While, as already said, there are some cases that are rapidly 
fatal, many do not seem to have any effect on the patient's 
health for years. The prognosis as to cure is always doubt- 
ful. Some cases, whether excised, or destroyed by other 
means, will return after a time. If they do return, they 
must be destroyed again. 

Epithelioma Contagiosum. See Molluscum. 

Epithelioma, Multiple Benign Cystic. Under this title 
Fordyce l places those cases formerly described under the 

1 Journ. Cutan. and Gen.-Urin. Dis., 1892, x., 459. 



278 DISEASES OF THE SKIN. 

names of hydradenomes eruptifs, syringo-cystadenome, epi- 
thelioma adenoides cysticum, and others, and reports two 
additional cases. It is characterized by the eruption of 
small, pale-yellow, pearly, pinkish, brownish, or reddish - 
brown tumors from pinhead- to pea-sized, that are located 
on the face, chest, back, and upper extremities. They are 
firm to the touch, and painless. Some of the tumors are 
tense, shiny, freely movable, sometimes with a central 
depression. Some are translucent, like vesicles ; some look 
more like milia. They slowly increase in number, the 
individual tumors enlarging to the size of a pea and then 
remaining stationary. The disease has no effect on the 
general health. In most cases it is hereditary. The 
diagnosis from adenoma sebaceum is very difficult, and 
often cannot be made without the aid of the microscope. 
It always begins in early life. 

Microscopic examination shows the tumor to be made 
up of irregular masses and tracts of epithelial cells, and 
"cell-nests." Colloid degeneration of individual cells 
is also seen in the cell-masses. There are also a down 
growth and proliferation of the epidermis and external 
root-sheath of the hair follicle. It is supposed that the 
growths are due to misplaced epithelial cells of indifferent 
nature. (Fordyce.) 

Their treatment is by curetting or th e 
edo extractor. 

Epitheliomatose Pigmentaire. See Atrophoderma pig- 
mentosum. 

Equinia. Synonyms : Glanders ; Farcy ; Malleus ; (Fr.) 
Morve; (Gr.) Rotz. 

A contagious, specific disease, with general and local 
symptoms, derived from the horse, ass, or mule. 

This is a rare disease in the human race, and runs an 
acute, subacute, or chronic course. It is derived by inocu- 
lation with the bacillus mallei, and its symptoms show 
themselves in from three days to six weeks afterward. Its 
constitutional symptoms are fever, prostration, constipa- 



ERYSIPELAS. 279 

tion, and rheumatic pains, with the subsequent develop- 
ment of a typhoid condition in which the patient dies. 
The objective symptoms are a profuse purulent or sanious 
nasal discharge ; chancroidal ulceration at the site of en- 
trance of the poison; phlegmonous inflammation of the 
affected part ; adenitis ; and a cutaneous efflorescence. 
The latter is a disseminated eruption of red macules, which 
develop into yellow papules, upon which variola-like pus- 
tules and bullae may form. These may coalesce into sup- 
erficial ulcerations and gangrenous patches. The skin is 
swollen and red, and often crusted with the discharge 
from the pustules. Infiltration of the subcutaneous tis- 
sues may occur and deep sloughs may form. There may 
be a general adenitis, and the glands may break down 
and form ulcerating cavities. The whole skin may be 
involved in these destructive processes. It may run an 
acute or chronic course. 

Treatment is usually unavailing in acute cases, and is on 
general principles. In chronic cases recently cures have 
been effected by the hypodermic use of mallein, a serum 
derived from cultures of the bacillus. The initial dose is 
1 milligramme, increasing in the course of a week or so 
to from 30 milligrammes to 1 gramme. The prognosis 
is bad. The more acute the symptoms the worse the 
outlook. 

Erbgrind. See Favus. 

Erysipelas. Synonyms: (Fr.) La rose, Feu sacre; 
(Ger.) Rothlauf, Rose, Hautrose, Wundrose ; (It.) Risi- 
pola ; St. Anthony's fire, Wildfire, Rose. 

An inflammatory disease of the skin or the adjacent 
mucous membranes, attended always with redness and 
swelling, and often with vesicles, bullae, pustules, diffuse 
suppuration, and gangrene ; and characterized by a ten- 
dency to spread at the periphery and by fever. (Foster.) 

Symptoms. Though the most modern pathology 
teaches that erysipelas always originates in or about a 
lesion of the skin or mucous membrane, and is therefore 



280 DISEASES OF THE SKIN. 

allied to if not identical with the same disease as met with 
in surgical and lying-in wards, so-called surgical erysipelas 
will not be considered here. The outbreak of the disease, 
as met with apart from the surgical form, is usually pre- 
ceded for a day or so with malaise, and the attack is often 
ushered in with a chill, pyrexia, and vomiting. The fever 
is present throughout the whole course of the disease, ex- 
cepting in the most mild type, when it may soon subside. 
The thermometric range is from 101° to 105.5 ° F. There 
will be other signs of constitutional disturbance, such as a 
coated tongue, a quickened pulse, either full, soft, and 
compressible, or, in bad cases, small and weak ; headache, 
drowsiness, or, in . bad cases, delirium ; and sometimes 
albumin is found in the urine. 

The most frequent location of the disease, so far as we 
now are concerned, is the head and face, though it may 
occur anywhere on the body. The eruption begins usually 
as a single patch, which is at once rosy red, swollen, 
sharply defined, irregularly shaped, hot to the touch, and, 
at first, with a smooth glazed surface. The redness may 
be pressed out with the finger, leaving a yellow stain, but 
promptly returns when the pressure is removed. The 
patch enlarges, creeping with more or less rapidity over 
the surface, always preserving its sharp, ofttimes indented 
border that is raised toward the sound skin ; it becomes of 
a darker hue, sometimes livid ; and very commonly, though 
not uniformly, vesicles or even blebs form on it. These 
latter may become purulent, and breaking, discharge their 
contents upon the surface, which dry into crusts. As the 
process extends the central portion becomes flattened and 
less red. Sometimes new patches may appear, and coal- 
esce with the original patch. Sometimes, while spreading 
peripherally, there may be a recrudescence in the older 
parts. The area of the disease may be limited or may 
include the whole body. Very often it seems to be 
checked by the line of the hair, whether of the beard or 
scalp. In only a small proportion of cases does it invade 
the hairy parts, involving one-half or the Avhole of the 



ERYSIPELAS. 281 

scalp and extending down upon the neck. Then the 
patient's appearance is indeed deplorable. His lips are 
swollen and livid, his eyelids are swollen so that the eyes 
cannot be opened, and his head seems enormously en- 
larged. At times there may be a lighting up of the dis- 
ease on a distant part of the body, as on the arm with 
erysipelas of the face. The lymphatics and the lymphatic 
glands are involved. The former often show themselves 
as red streaks. The glands may suppurate, and gangrene 
of the skin may declare itself. All grades of inflamma- 
tion may be reached. Sometimes the disease is but slight, 
sometimes very severe, the constitutional symptoms keep- 
ing pace with the severity of the local symptoms. The 
duration of the disease may be six or seven days, or two 
or three weeks. The patient is always more or less pros- 
trated by it, though many of the cases we see are ambu- 
lant cases. 

The subjective symptoms are burning, tingling, itching, 
and tension. The parts are often tender, and may be 
spontaneously painful. 

The disease quite commonly begins about the nose, and 
may invade the mouth. Occasionally it spreads rapidly 
over the surface as an advancing, broad, rosy-red, raised 
line. Sometimes recurrent attacks occur at short inter- 
vals ; generally the disease does not recur. When the 
scalp is invaded the hair commonly falls during conva- 
lescence. Sometimes some lesion of the skin may be 
found as the starting-point of the inflammation, or per- 
haps some lesion of the mucous membrane of the nose, 
mouth or ear. In the recurrent attacks the nose is quite 
commonly the peccant member. But in a very large 
proportion of cases no lesion at all will be discoverable. 
When the disease subsides the skin desquamates, and 
returns at last to the normal condition. 

Erysipelas occurring upon the trunk or extremities 
presents pretty much the same symptoms as when occur- 
ring upon the face. 

Etiology. It is now generally accepted that the dis- 



282 DISEASES OF THE SKIN. 

ease is infectious, and caused by a specific microorganism 
that was described by Fehleisen/ which is a streptococcus. 
This gains access to the body through some lesion of 
continuity of the skin or mucous membrane, however, 
minute that may be. It therefore sometimes follows 
boils, tubercular ulcers, eczema, and other skin diseases. 
As in many of the bacterial diseases, so in this one, it is 
probable that the patient must be in the proper condition of 
health, or rather ill-health, for the lodgement of the cocci. 
One attack predisposes to another attack. In frequently 
recurring cases infection probably takes place through 
some lesion of the nose or naso- pharynx. It is more 
frequent in women than in men ; and in winter than in 
summer. Intemperance, Bright' s disease, parturition, and 
a lowered state of nutrition predispose to it. While 
the contagiousness of surgical erysipelas is well known, 
and commonly observed, it is rare to meet a case of 
facial erysipelas traceable directly to contagion. The 
possibility of the occurrence of the disease without in- 
fection by the microorganism is still entertained. It 
lias been thought to arise from taking cold or to begin 
in some circumscribed purulent deposit. 

There is nothing specific about the pathological anatomy 
of the disease. 

Diagnosis. If the clinical features of the disease are 
kept in mind, the sharply defined, swollen, red patch ad- 
vancing with more or less steadiness over the surface, the 
process being preceded by a chill and accompanied by 
marked constitutional disturbance, there is little danger of 
not recognizing it. It may, however, be mistaken for an 
acute erythematous eczema, an erythema, or so-called 
giant urticaria. In eczema the parts are not so swollen ; 
the margin of the patch fades into the surrounding skin, 
the color is not so brilliant ; the surface is rougher and 
more scaly ; there is decided itching and a lack of con- 
stitutional disturbance of any magnitude Erythema lacks 

^Deutsche Zeitschrift f. Chirurgie, 1882, xvi., 391, 



ERYSIPELAS. 283 

the constitutional symptoms of erysipelas ; the redness 
fades completely away under pressure, without leaviug 
a yellowish stain, and springs back promptly when the 
pressure is removed ; it does not creep over the skin ; and 
it is of short duration. In urticaria there will usually 
be well-marked wheals or a history of them ; great itch- 
ing ; no tenderness ; a short course ; a history or evidence 
of digestive disorders, and an absence of marked consti- 
tutional disturbance. 

Treatment. The great variety of remedies that have 
been vaunted for the cure of erysipelas evidences the 
fact that most cases recover of themselves. There are 
not a few competent observers who are skeptical of the 
real efficacy of any local treatment. As the disease tends 
to lower the vitality of the patient we should strive to 
support his strength by a most nutritious diet, and by 
alcoholic stimulants in adynamic cases. The internal 
medication will be symptomatic to a large extent, by 
means of aconite, quinine, antipyrine, phenacetine, and 
the like. The tincture of the chloride of iron, in 20 
to 60 minim doses every two or three hours, is regarded 
by many as a specific, and should be given in all but the 
slightest cases. Jaborandi by the mouth, or pilocarpine, 
\ to J of a grain hypodermically, have their advocates, 
but must not be thought of in debilitated subjects. 

The local treatment is very important. If there is a 
wound present, it should, of course, be thoroughly disin- 
fected on surgical principles. The lead-and-opium wash 
is an old remedy, and has proved useful in very many 
cases. It is composed of 

li Liq. plumbi subacetat. dil., 3j-iij 5 4-12 

Tinct. opii, 3ij-iv; 8-16 

Aquae, ad Oj ; ad 500 M. 

It may be used hot or cold, whichever is most agreeable 
to the patient. Dry heat will also relieve the discomfort 
of the patient. Resorcin in watery solution of 2 or 
3 per cent, strength seems at times to cut short the 



284 DISEASES OF THE SKW. 

disease. Duckworth 1 commends chalk ointment, made 
of equal parts of melted lard and chalk, with or without 
\ drachm of pure carbolic acid to the ounce. This is to 
be smeared on thickly and covered with plain or borated 
lint. White lead paint has done well in some hands. 
AVhite 2 expects to cure his cases of ordinary facial ery- 
sipelas by keeping the part constantly covered with cloths 
saturated with the following : 

U Ac. carbolici, 5j j 4i 

AlcohoL ' \ aaOss; aa 250 „ 

Aquae, J ' 1Vi - 

It may be used every alternate hour. Carbolic acid may 
also be used in oil, 10 per cent, strength, and rubbed in 
every hour. Piffard recommends the external use of: 

}£ Tinct. belladonnas, 1 part. 

Glycerini, 1 " 

Aquae, 8 parts. M. 

Shoemaker is fond of the ointment of the oleate of 
bismuth. Iehthyol, in 25 to 50 per cent, aqueous solu- 
tion, is one of the best applications, the only objections 
to it being its disagreeable odor and dark-brown color. 
The parts should be constantly covered with it. 

The treatment by scarifications about the patch, the in- 
cisions being made diagonally, partly in the sound and 
partly in the diseased skin, and then covered with gauze 
wet with a solution of bichloride of mercury, 1 to 1000, 
is known as the Kraske-Riedel method, and should be 
always thought of in grave cases. Woelfler 3 recommends 
compression of the border-line by adhesive-plaster strips, 
the disease seldom spreading beyond the constricting 
band. This is specially applicable to erysipelas of the 
limbs. Painting with nitrate of silver all around the 
patch has also been done, with the idea of checking its 
spread. 

Prognosis. Many cases of erysipelas recover of them- 

1 Practitioner, January, 1887. 

2 Trans. Amer. Dermat Assoc. 1890, 42. 

3 Wien. klin. Wochenschr., 1889, Nos. 23 and 25. 



ERYTHEMA. 285 

selves in a few' days, while others may run a course of 
weeks. The prognosis may be said to be good in most 
cases ; but even in those that begin as mild ones we should 
be on the watch for grave symptoms. When the scalp 
is affected the prognosis is more grave than when the face 
alone is the seat of the disease. When the patient is the 
subject of chronic alcoholism, or Bright' s disease, or is in 
the puerperal state, or in either extreme of life, the prog- 
nosis is bad. 

Erysipeloid is a term employed by Rosenbach to desig- 
nate an erysipelas-like eruption unattended by constitu- 
tional symptoms. It is also called chronic erysipelas and 
erythema migrans. It originates in a wound, is due to 
infection from some dead, putrefying animal substance, 
and chiefly affects cooks, butchers, fishmongers, and the 
like. Gilchrist 1 has seen many cases as the result of crab 
bites and believes it is caused by some special ferment. 
It occurs mostly on the fingers, and spreads from the 
point of inoculation as a dark-red, often livid swelling 
with a sharp border. As it travels over the surface the 
central portion undergoes involution, and thus circles or 
scalloped patches may be formed. It stops spontaneously 
after from one to six weeks' duration. There is marked 
itching or burning during the whole course of the disease. 
It is distinguished from true erysipelas by the mildness of 
its symptoms. A salicylic acid or other antiseptic oint- 
ment may be used in treatment. Gilchrist found the 
most effective treatment is to strap the edge of the swell- 
ing with a 25 or 50 per cent, salicylic acid plaster. 

Erythema. Synonyms : Dermatitis erythematosa, Ery- 
sipelas suffusum ; (Fr.) Ery theme, Dartre erythemoide ; 
(Ger.) Ery them, Hautrothe ; Rose rash. 

Erythema may be passive or active. The former 
is familiar as lividity of the skin, and the latter as 
blushing. 

There are many forms of erythema as a disease, but 

1 Journ. Cutan. Dis., 1904, xxii., 507. 



286 DISEASES OF THE SKIN. 

they may all be classed under one of two main varieties, 
namely, Erythema hypersemicum and Erythema exuda- 
tivum. I shall follow Crocker's classification, as it is a 
practical one. It is a question whether erythema should 
be regarded as a disease or a symptom. 

C E. simplex, 
f 1. Due to external | E. pernio. 

causes -j E. intertrigo. 

I E. iseve. 
E. hypersemicuin \ LE.paratrimma. 

f E. fugax. 
J 2. Due to internal j E. urticans. 
Erythema i causes j E. roseola. 

IE. scarlatiniforme. 
f E. multiforme. 
E. exudativum J £• seu , Herpes iris. 
I E. nodosum. 
I.E, gangrenosum. 

Erythema Hyper^emicum. 

This form of erythema is characterized by simple red- 
ness without swelling, and usually is not followed by des- 
quamation. This shows that it is due simply to a local- 
ized hyperemia without inflammation. It is always of 
short duration. The redness disappears under pressure, 
but springs back again as soon as the pressure is removed. 
It occurs either in circumscribed patches of large or small 
size, or diffused over large areas. Subjective symptoms 
are often hardly noticeable. There may be some burning 
and tenderness, but there is never decided itching. The 
patient may rub his skin gently, but never scratches 
violently. In cases due to internal causes there may be 
slight constitutional symptoms with fever of mild grade, 
or some digestive disturbance ; but these are not properly 
symptoms of the erythema, but rather of the underlying 
disease of which the eruption is but an accidental expres- 
sion. For instance, two people may eat the same thing. 
In both there may be digestive disturbances. But one 
will have an erythema and the other will escape. 

This form of erythema may arise from either external 
or internal causes. Cases arising from external causes 
are localized, while those due to internal causes are gen- 



ERYTHEMA. 287 

eral. Both are angio-neuroses, and predisposed to by an 
inborn susceptibility — that is, idiosyncrasy of the patient. 

In the first group we have Erythema simplex, under 
which are included E. traumaticum and E. caloricum, due 
to the rubbing of the clothing, the effect of heat or cold, 
as of the sun or wind, and of various vegetable or chem- 
ical irritants. Many of these simple erythemas I have 
already described under the caption of Dermatitis, which 
see. They are the simplest reaction of the skin to an 
irritant. If the irritant is great enough or lasts long 
enough, a dermatitis is set up. They are usually local- 
ized, and for treatment require only the removal of the 
irritating cause, and the application of a simple dusting 
powder or ointment. The exciting cause continuing, we 
have inflammation added and a dermatitis produced. 

Erythema Pernio has been described under Dermatitis 
congelationis, which see. 

Erythema Intertrigo, or simply Intertrigo, is an ery- 
thema occurring between two folds of skin. It is most 
commonly seen in fat infants in the folds of the skin of 
the neck and joints. It is also encountered in adults who 
are corpulent, and is often a very annoying trouble in 
women, in whom it frequently occurs underneath the 
hanging breasts. It also occurs between the scrotum and 
inside of the thighs, under the prepuce, in the furrows 
alongside of the vulva, in the joints, and in all other skin 
creases. It is then caused by the friction in walking and 
favored by heat and moisture. It is therefore more 
common in warm weather. If not at once and properly 
attended to, the decomposition of the sweat and sebaceous 
matters will aggravate it ; and the irritation being con- 
tinued, an eczema will develop. It is, in infants, very 
common about the inside of the thighs, where the wet 
napkins cause and aggravate it. It is very often accom- 
panied by a disagreeable, cheesy odor, and, contrary to 
what obtains in other erythemas, there is moisture upon 
the skin in some cases. 

Diagnosis. The diagnosis from eczema is very often 



288 DISEASES OF THE SKIN. 

difficult. Indeed, eczema and erythema run into each 
other so imperceptibly at times that it is difficult to tell 
where the one leaves off and the other begins. But eczema 
itches more than erythema, it tends to spread further be- 
yond the affected part, and its exudation is not only sticky, 
but also stains and stiffens linen. The location in the 
skin-folds should suggest an intertrigo. Happily, the 
differentiation is a matter of no great importance, as the 
same treatment is applicable to both. 

In infantile syphilis we frequently have an eruption 
upon the buttocks and inside of the thighs that bears a 
decided resemblance to intertrigo. Here a correct diag- 
nosis is of great importance. In syphilis the redness com- 
monly extends down the whole inside of the legs to the 
feet and soles, it is of a darker color, and there will be 
other symptoms of the disease, such as snuffles, large or 
small papules to the outside of the red patch, mucous 
patches, and the like. In infant asylums, where a great 
number of debilitated as well as syphilitic children are 
received, opportunities for the differentiation between 
syphilis and intertrigo frequently occur. 

Treatment. The treatment of intertrigo is simple. 
The apposing surfaces of skin must be separated by pieces 
of gauze or muslin, the furrows must be kept perfectly 
clean, and dusting powders of starch, talc, lycopodium, 
and the like, must be freely used. To these powders 
oxide of zinc, boric acid, or other astringents may be 
added, the compound stearate of zinc being one of the 
best applications. Hardaway recommends : 

R Thymol., gr. j ; 106 

Pulv. zinci oleat., ^j; 32J M. 

Asa rule, powders answer better than ointments, though 
Lassar's paste, as given under Eczema, may be used. 
Lotions, such as calamine lotion, and a saturated solution 
of boric acid, are preferable to ointments. The treatment 
of intertrigo in infants is to be managed in the same way 
as eczema. (See under Eczema infantile.) 



ERYTHEMA. 289 

Erythema Lceve is an obsolete term, which was employed 
to indicate the redness seen on oedematous limbs. 

Erythema Paratrimma belongs to the same category, 
only here it is the redness over bony prominences, as that 
preceding a bedsore. 

We have now to consider the second group of erythema 
hypersemicum, those erythemas which are due to internal 
causes. Here might be placed all the exanthematous 
fevers, as well as the drug-eruptions. But the first of 
these belongs to the domain of general medicine, and the 
last will be found under Dermatitis medicamentosa. 

Erythema Fugax is, as its name indicates, a fugitive 
erythema— as it were, a prolonged blush. It occurs most 
often in children with some digestive disturbance, and its 
chosen location is the face. It lasts for a few moments 
or hours, and is seldom seen by the physician, although 
he will be told, not infrequently, by his patients that they 
are annoyed by a flushing of the face after eating, exposure 
to cold, or mental emotion. It is to be managed like 
Urticaria, which see. 

Erythema Urticans is simply the first stage of urticaria. 
The term should be dropped. 

Erythema Roseola, or simply roseola. While children 
are more subject to this form of erythema than adults, it 
may occur in the latter. Most commonly it affects the 
whole body, but it may be localized. As it is due in 
most, if not all, cases to digestive disorders or other con- 
stitutional disturbance, it is usually ushered in with a rise 
of temperature, which may be pretty sharp, 103° or 104° 
F., furred tongue, restlessness, and the like. Soon the 
eruption appears, which may be a blotchy redness, or in 
faintly marked papules, or in rings or gyrate figures. 
The eruption lasts a few hours only, or, coming and going 
in different places, it may be prolonged for a few days. 
Besides digestive disorders, gout, changes of temperature, 
and the seasons of spring and autumn have been assigned 
as causes. 

Diagnosis. In itself it is a matter of little moment, 



290 DISEASES OF THE SKIN. 

but as it resembles scarlet fever, rotheln, and measles, its 
diagnosis is important. It differs from scarlatina in not 
having such severe constitutional symptoms ; in an ab- 
sence of the strawberry tongue, swollen, reddened fauces, 
and enlarged glands ; in the rash coming out all over the 
body without following any regular course of development 
from the neck downward ; in the eruption being blotchy 
or papular, and not a diffused redness. After watching 
the case for a day the diagnosis will be made evident by the 
clearing away of the disease wholly or partially. It dif- 
fers from measles in an entire absence of catarrhal symp- 
toms, and in its eruption not being crescentic, as well as 
in the irregularity of its course, the mildness of its symp- 
toms, and the brightness of its color. It bears most re- 
semblance to rotheln, and probably the two are often con- 
founded. If there is a clear history of contagion, or 
more than one member of the family affected at the same 
time, the diagnosis of rotheln is at once established. 
Rotheln is more pronounced on the extremities, and the 
lesions are of a more stable character. In case of doubt as 
to the diagnosis of roseola the patient should be regarded 
as having a contagious disease, isolated, and carefully 
watched. 

Treatment. Little need be done for the patient but 
to give a laxative, and to relieve symptoms. 

Erythema Neonatorum makes its appearance in the first 
few days of life, and is thought to be due to the influence 
of external and unusual irritants acting upon the tender 
skin of a new-born child. " The eruption consists of very 
minute red papules, seated upon a hypersemic base, which 
can be made to lose their color upon pressure. The lesions 
are most pronounced upon the back and breast, and fade 
away in a few days with slight desquamation of the most 
congested spots. The mucous membranes are unaffected, 
and there is no evidence of systemic reaction." (Hard- 
away.) 

Erythema Scarlatiniforme. A scarlatina-like erythema 
follows the ingestion of a number of drugs, and has been 



ERYTHEMA. 291 

frequently mentioned in the section on Dermatitis medica- 
mentosa. The French authors describe a scarlatiniform 
erythema under the name of ery themes scarlatiniform 
recidivantes, which, according to Besnier, 1 who has pub- 
lished an excellent study of the affection, was first described 
by Fereol in 1876, at the Societe medicale des Hopitaux 
de Paris. The disease is marked by redness, desquama- 
tion, and relapses. Its outbreak may or may not be pre- 
ceded for one or two days by malaise and slight febrile 
movement. It begins on the trunk and invades the whole 
surface in a few hours or in two days. It is a diffused, 
uniform, intense, scarlatinal or sombre -red eruption. 
There may be slight differences in the shade of color, or 
the redness may be punctate, or some pinhead-sized ves- 
icles may develop upon it. Sometimes the eruption is 
limited to a certain portion of the body ; sometimes the 
eruption is general, but not universal, normal islands of 
skin being found in the general redness. It comes out in 
patches that run together. There is generally redness of 
the mucous membrane of the mouth and fauces. There is 
no thickening of the skin nor infiltration of mucous mem- 
branes. The skin burns, and there may be itching. Ex- 
foliation of the skin begins almost as soon as the eruption 
is out, commencing at the point of invasion. The des- 
quamation is general, and may be furfuraceous, or abundant 
and in large plaques. Upon the scalp it is furfuraceous. 
The whole process may take but one or two days, or it 
may be prolonged for a month or six weeks. The hair 
and nails may be shed. The tongue is furred, and may 
desquamate, but never presents the papillae of scarlatina. 
After the beginning of the attack there is usually no fever, 
and the appetite is preserved. There may be albumi- 
nuria during the attack. The relapses, which are apt 
to occur after intervals of days, months, or years, are 
less pronounced and the patient's health is good in the 
interim. 

Etiology. The cause of the disease is very often 

1 Ann. de derm, et de syph.. 1890, i., 1. 



292 DISEASES OF THE SKIN. 

obscure. The first attack has been observed to follow 
exposure to cold, the application of mercurial ointment, 
or the action of some other irritant. But it is difficult to 
explain why from such causes relapses should occur. 
Besnier thinks that in some cases the cause is a poison 
developed within the individual. In this way he would 
explain some of the erythemas developing during an acute 
urethritis, which some observers claim may arise indepen- 
dently of the taking of copaiba. Scarlatiniform erythemas 
occur occasionally in septicemic conditions, in typhus fever, 
in malaria of children, in sewer-gas poisoning, and in 
various other conditions. 

Diagnosis. Brocq considers scarlatiniform erythema 
as one form of dermatitis exfoliativa, but it is distinguished 
from it by an absence of evening rise of temperature, by 
having no permanent effect upon the health, by running a 
shorter course, and by the skin not being dry, contracted, 
and shrivelled. It differs from scarlatina in the mildness 
of its constitutional symptoms ; by the course of the erup- 
tion ; by the absence of tumefaction of the fauces and the 
strawberry tongue; by the early desquamation; by not 
being contagious ; and by its tendency to relapse. If there 
is any doubt as to the diagnosis, the patient should be 
isolated. It differs from measles in the absence of catarrhal 
symptoms and Koplik\s spots in the mouth. It differs 
from erythematous eczema in an entire absence both of 
thickening and moisture ; in being less itchy ; and in its 
rapid course. 

Treatment. The treatment is purely symptomatic. 

Erythema Exudativum. 

The second variety of erythema differs from erythema 
hypersemicum in the presence of an exudation into, not 
on, the skin, so that the patches are raised above the level 
of the skin, and in never involving the whole surface, but 
always occurring in circumscribed patches. It is an in- 
flammatory disease. Its several varieties are alike in that 



ERYTHEMA. 293 

the redness disappears under pressure, to return at onee 
when the pressure is removed. It is probable that ery- 
thema nodosum is really but a part of erythema multiforme, 
as the two forms may be present at one time. But it is 
usually described apart, and although this may not be 
strictly accurate, it is convenient. 

Erythema (Exudativwni) Multiforme, as its name indicates, 
is very multiform in its efflorescences. For a day or a few 
days before they appear there is some constitutional dis- 
turbance. This may be nothing more than slight malaise, 
the patient not feeling as well as usual. From these 
indefinite symptoms there are all grades up to fever of 
104° F., headache, gastric disturbances, and severe muscu- 
lar and articular pains, like rheumatism. According to 
Besnier and Doyon, an erythema of the pharynx, or a 
pharyngitis, laryngitis, or bronchitis, often precedes or 
accompanies the outbreak of the eruption upon the skin. 
The eruption is most constantly seen upon the backs of 
the hands and feet, and here it commonly begins, though 
this is denied by Polotebnoff, to whom we are indebted for 
a most exhaustive and able study of erythema. 1 It also 
appears on the trunk and extremities more or less gener- 
ally, coming out in crops, and preserving a rough sym- 
metry. Sometimes it may remain confined to a single 
region, as the backs of the hands. Sometimes it occurs on 
the mucous membranes, as of the mouth and eyes. It is 
usually most marked and abundant about the joints should 
they have exhibited rheumatic, pains. It is rare not to 
find lesions upon the backs of the hands. "With the ap- 
pearance of the eruption there is a subsidence of the con- 
stitutional symptoms, though in many cases the patients are 
more or less definitely ill during the whole course of the 
disease. 

The eruption commences as a group of deep-red papules 

from pinhead- to pea-size, conical or rounded, and this is 

called erythema papulatum. The eruption may continue 

as such ; or the papules may coalece and form elevated 

1 Zur Lehre von den Erythemen. Hamburg, 1887. 



294 DISEASES OF THE SKIN. 

patches, sharply marked against the sound skin ; or they 
may enlarge to the size of tubercles, thus forming erythema 
tuberculatum. If they still continue to enlarge, they be- 
come depressed in the centre and ring-shaped, the periphery 
being deep red while the centre is purplish. This is called 
erythema eircinatum or annulare. Sometimes it happens 
that the ring still enlarges by successive exudations, and 
then there will be ring within ring, the outer one pink, the 
next red, the next purplish, thus forming an iris-likeplay of 
colors that has been termed erythema or herpes iris. Two 
rings near each other and enlarging will after a time meet 
at their peripheries, the points of contact will melt into each 
other and disappear, and there will form a large patch with 
a figure-of-eight or scalloped, raised border, and a flattened 
centre. This is called erythema marginatum. It may 
travel over a large part of the trunk or the circumference 
of a limb, leaving a fawn-colored pigmentation, which soon 
fades. Or two rings meet, and each breaks, and only a 
gyrate line is formed, to which the name of erythema 
gyratum is applied. Sometimes, though rarely, the exuda- 
tion is so abundant that the epidermis is raised in the form 
of vesicles or bullae. This is erythema vesiculosum seu 
hullosum. Hemorrhage may take place into the bullae. 

It is uncommon to find all these forms present at the 
same time, nor must it be understood that one form neces- 
sarily evolves into the other. The evolution may stop at 
any stage ; most often at the papular stage. Neverthe- 
less, more than one form is usually to be seen, so that the 
term multiform is merited. Crocker says that in children 
multiformity is less the rule, the constitutional symptoms 
are more pronounced, and if vesiculation occur the vesi- 
cles are more prone to become purulent and leave scars. 

The duration of the disease is from two to four weeks, 
but it may be extended by a succession of outbreaks for 
months or years. Very infrequently a given lesion may 
persist for weeks. This is erythema perstans. The erup- 
tion is attended by burning rather than itching, and some- 
times by a feeling of tension. Slight pigmentation may 



ERYTHEMA. 295 

be left, but it is transitory. Desquamation may follow 
the eruption, but it is not common. In some patients 
there is a decided tendency to relapse at irregular inter- 
vals for years. In Prof. George Henry Fox's service at 
the Vanderbilt Clinic, I have seen a boy with a relapsing 
bullous erythema of the face and ears that had appeared 
at intervals during ten years. The bullae were of large 
size, fully distended, and of irregular shape. They left 
depressed, pigmented cicatrices in some places. Similar 
cases have been reported by others, as, for instance, by 
Hardaway, who saw one case with relapses for four years ; 
and T. C. Fox, who saw two cases with a duration of six- 
teen years in each'case. 

As complications of erythema multiforme, and espe- 
cially of erythema nodosum, have been reported endo- 
and pericarditis, meningitis, pleurisy, pneumonia, and the 
like ; but it is better to regard these diseases not as com- 
plicating the erythema, but as the primary diseases of 
which the erythema is a phenomenon. 

Erythema Iris. This very rare disease was formerly re- 
garded as a herpes, and is described in many text-books as 
herpes iris. Its other synonyms are hydroa, herpes circi- 
natitSj and hydroa vesiculeux . It is only a form of ery- 
thema multiforme. It is seen sometimes along with other 
manifestations of erythema multiforme, or with herpes, 
though it usually occurs alone. It is located most often 
upon the backs of the hands and feet, and upon the arms 
and legs, but it may occur anywhere upon the skin as well 
as the mucous membranes. According to Crocker, 
there are two varieties of the disease, one with a central 
vesicle or a purplish depression surrounded by one or 
more whitish rings slightly raised up by effused fluid; 
the other with a central bulla with one or more rings of 
more or less discrete vesicles round it. Of these two, 
the first is the more frequent. 

The first variety begins as a small erythematous papule 
upon which a pinhead-sized conical vesicle forms in about 
twelve hours. The vesicle grows larger and flattens, but 



296 DISEASES OF THE SKIN. 

preserves a red areola. When about a quarter of an ineh 
in diameter the fluid is absorbed in the centre, leaving a 
purplish depression ; or only a ring of absorption occurs, 
so that there will remain a vesicle in the centre with a 
purplish zone about it, then a raised white ring, and 
around all a narrow pink areola. This play of colors 
gives the name of iris. The patch may reach the diameter 
of half an inch, and then undergo involution ; or several 
patches may unite and form patches of one inch or more 
in diameter, and hemorrhage may take place into the 
bulla? that may form. 

In the second variety, which is the hydroa vSsiculeux 
of Bazin, round a central bulla a riug of split-pea-sized 
vesicles forms, the vesicles being either discrete or touch- 
ing. A second or a third ring of vesicles may form out- 
side of these, the skin between them being of a purplish 
tint. The bullae and vesicles may leave scars. Crusting 
also takes place from the breaking or drying of the vesi- 
cles. 

The lesions of both varieties are more or less symmet- 
rical, though a patch may develop on one side several 
days before the other. The duration is from three to 
four weeks or longer. Relapses are common. Burning 
is usually pronounced, and there may be some itching. 
From this description it will be seen that the so-called 
herpes iris is really an erythema. 

Erythema Nodosum, also called dermatitis contusiforme, 
and Zrytheme noueux (Fr.), is more common than ery- 
thema iris, but not nearly so common as erythema multi- 
forme. It is only a variety of erythema multiforme, as 
it may occur as a part of that disorder. In the vast ma- 
jority of cases it occurs alone. Its prodromal symptoms 
are substantially the same as those of erythema multi- 
forme, but its rheumatic pains are more pronounced and 
nearly always present. There are also tenderness and pain 
over the tibiae. After a few days of prodromata, round or, 
more often, oval, bright or rosy-red swellings appear over 
the tibiae, with their long axis vertical. These are from 



ERYTHEMA. 297 

nut- to egg-size ; raised ; their borders merge gradually 
into the surrounding skin ; they are painful and often ex- 
quisitely tender ; firm at first, they may be semi-fluctuating 
afterward ; and their color darkens to a dark red, then 
purple, and in undergoing absorption they present the 
appearance of a black-and-blue spot from a bruise. The 
color at first disappears under pressure, to spring back 
when the pressure is removed. The changes of color 
subsequently seen are due to the gradual absorption of 
the coloring-matters of the blood deposited in the tissues. 
There are usually not more than a dozen lesions, gener- 
ally less. They are most frequently located over the 
tibiae, but may occur as well upon the arms, scapulae, 
thighs, and mucous membranes. They are roughly sym- 
metrical. The duration of the disease is, like that of 
other erythemas, two to four weeks. 

Etiology. The causes of erythema exudativum are 
not fully determined. It is probably due to some toxic 
condition of the blood, which may develop in the indi- 
vidual or be derived from without. It occurs more 
commonly in women than in men, and in young adults 
rather than in old people, while erythema nodosum is said 
to be most frequent in children. It is most frequent in 
the spring and autumn seasons, in which dampness and cold 
winds prevail, and sudden changes of temperature are com- 
mon. The papular erythema is very often seen in recently 
arrived immigrants. Rheumatism has a well-marked 
casual relation to erythema nodosum, and, it may be, to the 
other forms. Syphilis seems to be an etiological factor of 
some weight in the production of erythema nodosum. 
Many cases seem to be due to systemic poisoning either 
by some infectious disease or by auto-infection. Some 
authorities are of the opinion that such cases should be 
separated from eythema exudativum, and propose the 
name of polymorphous erythema. It is seen with cholera, 
influenza, and the exanthemata ; with indigestion, preg- 
nancy, parturition, menstrual disturbances, kidney dis- 
eases, and various other internal or systemic disorders. 



298 DISEASES OF THE SKIN. 

Sometimes the disease seems to be a pure angio-neurosis. 
Cases of erythema multiforme recurring with recurring 
attacks of gonorrhoea have been reported. These appear 
as reflex angio-neuroses without the ingestion of balsamics 
in the treatment of urethritis. Cases of erythema multi- 
forme not infrequently follow the ingestion of drugs ; at 
least they are almost identical with it in appearance. 
Sometimes, according to Polotebnoff, it seems to be an 
abortive form of prevailing epidemics. Cases certainly 
should be watched carefully in connection with other 
symptoms, as they may be but part of the prodromata of 
some grave disorder ; I have seen two cases in which a 
well-marked erythema multiforme preceded for about ten 
days the outbreak of typhoid fever ; the erythema then 
disappearing and the characteristic typhoid eruption com- 
ing in due course. Many of the subjects of erythema are 
debilitated. Individual predisposition probably plays an 
important role in the etiology of some cases, especially 
in the relapsing ones. 

Pathology. All forms of the disease show not only 
hypersemia, but also inflammatory effusion both of fluid 
and leucocytes. Upon the amount of this fluid depends 
the character of the lesion. If small in amount, it will 
simply push up the epidermis into a papule or tubercle ; 
if of larger amount, we shall have vesicles and bullae. 
There is also an escape of the coloring-matter of the 
blood in the tissues. (Crocker.) 

Microscopically the papillary layer is seen to be the 
seat of the principal inflammatory changes ; edema, dila- 
tation of the vessels, diapedesis, emigration of white 
corpuscles, and proliferation of the fixed tissue cells about 
the vessels. The covering of the bullse and vesicles may 
consist of the whole epidermis, or of only part of it. 

In erythema nodosum in addition to these changes, 
phlebitis of the larger subcutaneous veins has been found, 
and the frequent presence of white thrombi in the vessels. 
The epidermis rarely shows pathological changes. 

Diagnosis. If the characteristics of erythema multi- 



ERYTHEMA. 299 

forme are borne iu mind, little difficulty in diagnosis will 
arise. These are the sudden occurrence of raised, bright 
or rosy-red lesions, located by preference upon the back 
of the hands and feet ; the color that fades away en- 
tirely under pressure, to return again when pressure is 
removed, and disappearing leaves stains. It most resem- 
bles urticaria, but differs from it in having more stable 
lesions of more varied shape ; in absence of wheals ; 
in occurring particularly on the back of the hands and 
feet ; and in burning rather than itching. The papular 
form differs from papular eczema in its chosen locations ; 
in its burning rather than itching ; in its papules being 
larger and never developing vesicles nor forming patches ; 
in an absence of thickening of the skin ; in disappearing 
completely under pressure ; in tending to get well without 
treatment ; and in leaving stains. The nodes of erythema 
nodosum differ from syphilitic gummata in occurring sud- 
denly and not gradually. In syphilis the redness does 
not occur until after the node has existed for some time, 
and the nodes are not tender nor developed symmetri- 
cally. Moreover, there would be other evidences of 
syphilis. 

Treatment. Villemin 1 maintains that iodide of po- 
tassium, in doses of at least 30 grains a day, is almost 
a specific, and will abort relapses. The experience of 
Besnier and others has not been in accord with that of 
Villemin. Quinine, 20 or 30 grains a day, and salicy- 
late of soda in 1 5 grain doses three or four times a day 
sometimes abort or check the disease. Adrenalin, 1 in 
1000 has been recommended as a specific. The dose is 
10 drops, which may be repeated every three or four 
hours, watching its effect. As this is a new remedy it 
must be used with care. Arsenic may be tried in chronic 
cases. 

The treatment is mainly symptomatic, and directed 
to relieving the constipation, regulating the diet, aiding 
digestion, ameliorating rheumatism, or toning up the sys- 
i Gaz. hebdom., May 24. 1886. 



300 DISEASES OF THE SKIN. 

tem. In obstinate cases the patient had best be kept in 
bed. 

Locally any alkaline lotion will afford relief, such as 

]£ Pul. calamin. praep., £)ij ; 41 

Zinci oxid., £ss; 3 

Liq. calcis, ad 5ij ; ad lOOJ M. 

Or, 

]£ Liquor plumbi subacetatis, TT\xv; 3| 

Aquae, 5J ; 10o| M. 

Or, lead-and-opium wash, hamamelis, or other evaporat- 
ing solutions. Ointments should be avoided, as they 
do no better than lotions and are disagreeable to use. 
Sometimes a simple dusting powder will do as well. In 
erythema nodosum the patient should be kept in bed, and 
the lotion is often more agreeable to the patient when used 
warm. Salicylic acid or salicylate of soda internally may 
afford relief to the sometimes intense pains. Regulation 
and simplification of the diet, and the administration of 
diuretics or tonics, according to the nature of the case, 
will do good in the disease as seen in immigrants. 

Prognosis. The disease tends to spontaneous cure. 
Relapses may occur, though they are by no means the 
rule. Exceptionally the disease may run a protracted 
course, but recovery may be expected. 

Erythema Centrifuge. See Lupus erythematosus. 

Erythema Elevatum Diutinum. Under this caption 
Crocker * and others describe a form of erythema that is 
said to occur in girls with a rheumatic history. It devel- 
ops over the articular prominences of the fingers, elbows, 
and knees, and also on the palms, toes, and buttocks. Its 
lesions are nodular, with a tendency to coalesce into ele- 
vated infiltrations that are most marked on the palms. 
They tend to persist, but may undergo involution. Their 
color is at first pink, but soon becomes purple. The older 
lesions become firm and almost cartilaginous, and are 
always incompressible. The lesions are always sharply 

1 Brit. Journ. Dermat., 1894, vi., 1. 



ERYTHEMA. 301 

defined against the skin. Histologically the disease is an 
inflammatory process accompanied by the production of 
fibrous tissue. The treatment is unsatisfactory. 

Erythema Epidemicum. See Acrodynia. 

Erythema Gangrenosum. See Dermatitis gangrenosa. 

Erythema Induratum Scrofulosorum is a disease first 
described by Bazin as erytheme indurS des scrofuleux. 
It consists in an eruption of nodular lesions that may 
remain deep seated for a considerable time, so that they 
can be made out only by palpation. There may be but 
one lesion or many. After a while the overlying skin 
becomes red, and later violaceous, and the lesions resemble 
those of erythema nodosum. In size they vary from that 
of a hazelnut or larger on the legs, to smaller on the 
fingers. They are round or ovoid in shape and doughy 
to the touch. They are usually few in number and dis- 
crete, but may be numerous and confluent, and form large 
brawny infiltrations. They are indolent in their course, 
and may undergo involution, or suppurate or necrose en 
masse. Polycyclic ulcers may form which heal slowly 
with scarring, or remain sluggishly open. There may or 
may not be pain or tenderness. They are located most 
often on the calve of the legs in young people, especially in 
young women of poor general health and circulation, who 
stand a great deal and who suffer from chilblains in win- 
ter, but may occur in others who present none of these 
peculiarities. 

Pathology. Inflammatory and degenerative changes 
affect the vessels, and giant cells are present in large 
numbers. The lesion has been compared in its appear- 
ance to a necrotic tubercle. 

Diagnosis. They differ from erythema nodosum in their 
more circumscribed form, firmer consistence, darker color, 
deeper seat, absence of tenderness, tendency to ulcerate, 
and more protracted course. Syphilitic gummata are not 
bilateral, and usually other symptoms of syphilis can be 
found. 



302 DISEASES OF THE SKIN. 

The treatment consists in rest in bed, elevation and 
compression of the legs, and general tonics. Hutchinson 
recommends an ointment of the bisulphuret of mercury, 
5 grains in benzoated lard, 1 ounce. 

Erythema Migrans. See Erysipeloid. 
Erythema Serpens. See Erysipeloid. 
Erytheme Noueux. See Erythema nodosum. 
Erytheme Papuleux Desquamatif (Yidal). See Pityri- 
asis maculata et circinata. 

Erythrasma. A contagious parasitic disease of the skin, 
occurring especially in the groins and axillae in the form 
of sharply denned, brownish-red, desquamating patches, 
bordered by a fringe of broken and partly detached epi- 
dermis. (Foster.) 

Symptoms. The disease begins as little reddish brown 
or orange red points that soon become lentil-sized macules, 
which coalesce in a patch the size of a silver dollar, on the 
hand. Several patches join together, so that large surfaces 
may be involved. The patches are oval or disk-shaped, 
or irregular in outline. The color of the patches is orange, 
red, yellowish, or brownish, or, in the folds of the skin, 
pale red. Their outline is sometimes marked by a rais- 
ing of the epidermis. Their surface is dull-looking, and 
feels less smooth than normal and shows slight furfurace- 
ous desquamation. They are quite tenacious, cannot 
readily be rubbed off, and show little tendency to spon- 
taneous recovery. There may be slight itching. They 
are located in the situations where intertrigo is liable to 
occur, such as the axilla?, groins, and where the scro- 
tum comes in contact with the thighs. The latter situa- 
tion is declared by Besnier to be nearly always the origi- 
nal site of the disease. From these favorite locations 
the disease may spread to the chest, abdomen, or thighs. 
Besnier 1 met with a case involving the thigh down to the 
knee. 

Etiology. The disease occurs most often in men, 

i Journ. de Med. et de Chirurg. prat., 1883, liv., 351. 



EB YTHB ODERMIA. 303 

and never in children. It is rarely seen in this country. 
It is due to a parasite called the microsporon minutissi- 
mum, which is described by Balzer 1 as consisting of long 
wavy mycelia, that are rarely branched ; and of very fine 
spores. High powers of the microscope are necessary to 
see them. They are located exclusively in the corneous 
layer of the skin. He regards them as a common form 
of parasite that produces the disease in some people only 
on account of the peculiar fermentation of their skin 
secretions. 

Diagnosis. The disease resembles chromophytosis, 
eczema marginatum, and chloasma. It differs from 
chromophytosis in the darkness of its color ; in the ab- 
sence of distinct, rather large scales that can be lifted by 
the nail ; in its location, sparing the trunk, except by 
extension ; and in the character of the microscopical ap- 
pearances. From eczema marginatum it is distinguished 
by an absence of all inflammatory symptoms, by not 
being more pronounced at the periphery than at the 
centre, and by the microscopical appearances. From 
chloasma it differs in being a parasitic and not a pigmen- 
tary disease, in the change it causes in the feel and tex- 
ture of the skin, and in the effect of treatment. 

Treatment. It is curable by the same means as is 
chromophytosis, namely, by a saturated solution of the 
hyposulphite of soda ; tincture of iodine ; pyrogallol ; 
chrysarobin ; bichloride of mercury ; or sulphur. It is 
more obstinate than is chromophytosis, and quite as 
prone to relapse unless thoroughly eradicated. 

Erythrodermia, Congenital Ichthyosiform. This disease 
is described by Brocq 2 as a chronic generalized redness 
of the skin which may be so slight as hardly to attract 
attention, or so intense as to resemble pityriasis rubra or 
pemphigus foliaceus. There may be a marked hyper- 
keratosis shown as an exaggeration of the papilla? of 

1 Ann. de derm, et de syph., 1884, v., 597. 

2 Annal. derni. et syph., 1902, iii., 1. 



304 DISEASES OF THE SKIN. 

the neck and folds of the large joints, giving an appear- 
ance like acanthosis nigricans without the black color. 
There may be keratosis of the palms and soles; abun- 
dant pityriasis of the scalp ; deformity of the nails, and 
bullae. The disease is congenital. The etiology is ob- 
scure. 

Diagnosis It differs from ichthyosis in its red color, 
its papular formation, and its involvement of the joints ; 
from pityriasis rubra pilaris by beiug congenital, involv- 
ing the whole surface at once, by the different character 
of its scaling, and by absence of papular formations about 
hair follicles ; from pityriasis rubra by being congenital, 
by not affecting the geueral health in spite of its ch Ton- 
icity, and by the character of its scaling. Treatment is 
of no avail. 

Erythrodermie Pityriasique en Plaques Disseminees. See 
Parakeratosis variegata. 

Erythromelalgia is a nervous disease characterized by 
the appearance of a persistent patch of congestion, often 
on the sole of the foot, attended with swelling, itching, 
and pain (Foster.) Hyperidrosis is often marked. It is 
a symptom in various grave diseases of the brain and 
spinal cord. 

Esthiomene. This is a disease of the vulvo-anal region 
that was described by Huguier, 1 and about which there 
is a good deal of uncertainty. It has been variously con- 
sidered as a form of lupus, syphilis, elephantiasis, and 
epithelioma. "It is characterized by a leaden or vio- 
laceous hue of the parts, and their simultaneous alteration 
of shape, induration, thickening, ulceration, destruction, 
hypertrophy, and infiltration, so that the orifices and 
canals of the vulvo-anal region may be at the same time 
ulcerated, enlarged, and constricted, and its grooves and 
cutaneous and mucous folds exaggerated, thickened, and 
the seat of more or less extensive and deep ulcerations 

1 Mem. de l'Acad. de Med., 1869, p. 507. 



FAVUS. 305 

and cicatrices ; without pain, without directly threaten- 
ing life, and for a long time without affecting the consti- 
tution." (Foster.) 

Farcy. See Equinia. 

Favus. Synonyms : Porrigo lupinosa, seu favosa, seu 
lavalis, seu scutulata ; Porrigophyta ; Tinea favosa, seu 

Fig. 32. 



Favus capitis (Fox.i) 

vera, seu ficosa, seu lupinosa, seu maligna ; Trichomykosis 
or Dermatomycosis favosa ; (Fr.) Teigne faveuse, Teigne 
du pauvre ; (Ger.) Erbgrind : Crusted or honeycomb ring- 
worm, Scall head, True porrigo. 

1 G. H. Fox : Skin Diseases of Children. New York, 1897, 
20 



306 DISEASES OF THE SKIN. 

A contagious vegetable parasitic disease due to the 
Achorion Schoenleinii, and characterized by the presence 
of discrete or confluent, circular, pale sulphur-yellow 
cupped crusts, or by asbestos-like masses of grayish fri- 
able crusts ; by loss of hair producing irregularly shaped, 
disseminated, red, bald patches ; by permanent atrophy of 
the scalp ; and by running a chronic course. 

Fig. 33. 




Favns of knee. 



Symptoms. Favus affects both the scalp and the non- 
hairy skin as well as the nails and mucous membrane. 
We shall first describe it as it affects the scalp. A lesion 
of continuity, however slight, is probably necessary for 
contagion to take place. In a case of favus in a newborn 
child the period of incubation was found to be from six 
to eight days. It begins either as one or more scaly ery- 
thematous spots ; or as minute yellowish pun eta ; or as a 
group of vesicles smaller than those met with in ring- 
worm. These develop into small sulphur-yellow cupped 
crusts about the hairs. When the case is seen by the 



FAVUS. 307 

physician the early stage is usually passed, and he will 
find that the hair is dry and lustreless, and has fallen out 
in places, leaving irregularly shaped bald patches, of all 
sizes, and of pronounced red color. Upon both the bald 
patches and the parts still covered with hair the sulphur- 
yellow cup- or saucer-shaped crusts will be found, with 
raised or rounded edges, and with one or several hairs 
growing out of the middle of them. There will be more 
or less scaling, and, if the disease be of some age, thick 
mortar-like crusts of grayish color. In some cases when 
first seen it may be impossible to find the characteristic 
crusts — scutula as they are called — they being obscured 
by the mortar-like masses. In some cases the scutula are 
wanting. If we approach near enough to the patient, we 
will appreciate a peculiar odor variously described as that 
of mice, straw, or of a menagerie. 

The crusts, or scutula are situated about the hair fol- 
licles. They are from pinhead- to split-pea-size, accord- 
ing to age. At first they are covered with a thin layer of 
epidermis, but later the edges are free. When they are 
picked off they leave a moist depression which soon fills 
up, or a pustule, or an atrophied spot. The color is pale 
or sulphur yellow, or, if of long standing, it may be a 
dirty or greenish yellow. The crusts are discrete and 
disseminated or grouped ; sometimes they coalesce ; they 
are firm to the touch, and when crushed between the 
fingers impart a feeling of crumbling like mortar. There 
is a zone of slight redness about them. Though they may 
not be seen at the first examination, if the scalp is cleaned 
off and left to itself they will form in the course of two 
or three weeks. The baldness is rarely in well-defined 
patches. The patches may be few in number, or so 
numerous that the hair occurs only in islands. At first 
their color is inflammatory red ; later they become white 
and atrophic in appearance. The baldness is permanent. 
The hair is dry from the first; later it becomes brittle 
and splits longitudinally ; but it is never so easily broken 
as in ringworm, and can easily be pulled out with its 



308 DISEASES OF THE SKIN. 

roots. There is itching of the scalp. That is the only 
subjective symptom. Pustulation does not belong to the 
disease, but may be an accidental complication. Other 
complications that may arise are pediculosis, eczema, and 
enlargement of the cervical glands. 

Occurring upon non-hairy parts favus undergoes mate- 
rially the same development and forms the characteristic 
cups. Sometimes it will take the circular form of a 
ringworm with the development of vesicles, and resemble 

Fig. 34. 




Favus of hand, showing scut u la. Side view. 

it very closely, only that the cups will be sure to develop 
somewhere. (Figs. 33, 34, and 35.) The scutula develop 
around the lanugo hairs. There may be only one patch 
of favus or a large part of the body will b'e covered by 
the fungus growth in the form of sulphur-yellow cupped 
crusts and asbestos-like masses. On the non-hairy parts 
the disease is easier of cure than on the scalp, and is not 
so apt to leave scars. In a single case, that of Kaposi, 
the favic fungus was found implanted upon the mucous 
membrane of the stomach The nails may be affected, 
either in the form of onychitis beginning at the side of 
the nail, hardly distinguishable from the same disease de- 
veloped from common causes ; or in having a scutulum 



FAVUS. 



309 



develop in the nail-bed and show through the nail. This 
is rare. The occurrence of favus upon the head will 
give a cine to the origin of the onychitis. 

Etiology. The disease is due to the implantation and 
growth of the Achorion Schoenleinii primarily in the scalp 
and secondarily in the hair. It is contagious, but not so 
much so as is ringworm. It used to be rare in New York 
City, but on account of its being constantly imported from 
Europe, the disease is on the increase, and cases occur in 

Fig. 35. 




Favus of hand. Front view. 



native Americans, mostly of foreign parentage. Its course 
is very chronic, and it shows less tendency than ringworm 
does to spontaneous recovery about the time of puberty. 
Though children are more commonly affected than are 
adults, it is by no means uncommon to see it in full 
activity in people well advanced in life. It has been as- 
serted that the strumous diathesis predisposes to favus, 
but this is doubtful. Like all other parasites, it requires 



310 



DISEASES OF THE SKIN. 



a certain soil upon which to grow, and does not affect all 
skins. Neglect of personal hygiene favors its spread. 
It is a common disease in mice, and may occur in rabbits, 
dogs, cats, and fowls, and thus be a source of contagion 
for the human race. 

Pathology. The cups are composed almost wholly 
of the fungus, which consists of flat, narrow, branching 
and inosculating mycelial threads ^-J-^-th of an inch in 
diameter, and of pale-gray color ; and of small spores of 
round, oval, flask, or dumb-bell shape, and of a pale-green- 
ish color. (Figs. 36, 37.) The spores gain access to the 

Fig. 36. 




Achorion Schoenleinii. (After Kaposi 



skin by the orifices of the hair follicles, and, after remain- 
ing there undisturbed, begin to grow in the upper part of 
the hair sac, and between the superficial layers of the epi- 
dermis, and subsequently invade the hair, growing in its 
cortical substance. The cup may be formed either by the 
sinking in of the more central portion of the mass, or on 
account of the central portion being attached to the hair 
so firmly that it cannot so readily give way aud bow out 
uuder the pressure of the growing fungus as do the parts 
farther away from the hair. The atrophy of the skin is 
largely due to the pressure of the growing fungus, which 
is powerful enough to destroy the cranial bones of mice; 
and in part to the inflammation of the skin produced by 
the presence of the fungus. 



FA VUS. 



311 



The question of the unity or non-unity of the fungus 
of favus is still unsettled. Several fungi — Quincke says 
three, and Unna asserts that there are nine — seem capable 
of producing the clinical picture of the disease. Other 



Fig. 37. 




Achorion Schoenleinii in hair shaft and follicle. (After Kaposi.) 

competent bacteriologists hold that the apparently diverse 
fungi are either different stages of development of the 
same fungus or due to different culture-media. All varie- 
ties of the achorion produce the same clinical picture. It 
is distinct from the trichophyton fungus. 

Diagnosis. Most cases of favus are, easy of diagnosis ; 



312 DISEASES OF THE SKIN. 

the sulphur-yellow cupped crusts ; the asbestos-like gray- 
ish mass ; the red, atrophic bald spots, with tufts of dry 
and more or less kinky hair in them; and the peculiar 
odor, being so well marked. Ringworm has none of these 
features. Moreover, it occurs in the form of circular, cir- 
cumscribed, only partially bald patches covered with gray- 
ish scales, in moderate amount ; has characteristic nibbled- 
off "stumps" of hair; and under the microscope we find 
the spores less abundant, smaller, and more uniformly 
round than in favus. It must be confessed, however, that 
without the clinical features of one or the other disease, 
none but a most expert microscopist could make the diagno- 
sis in a doubtful case by the microscope alone. In eczema 
baldness is very rare, and we will usually find a character- 
istic patch of the disease behind the ear ; its crusts are 
greenish and tenacious, not gray and friable ; the hair is 
matted by the sticky exudation ; and if discrete impetigo 
lesions are present, they will contain pus, and not be solid 
like the favus crust. Leaving the scalp alone for a time 
will decide the matter, as scutula will be sure to form if 
the disease is favus. Seborrhoea causes a general thin- 
ning of the hair, the scalp is not atrophic, there are no 
scutula, and no achorion in the hair and scalp. Lupus 
erythematosus resembles favus only in producing atrophic 
red spots. There will usually be patches of the disease 
elsewhere, and its whole course is different. Psoriasis 
does not cause atrophic bald spots, and rarely occurs on 
the scalp alone. Alopecia areata presents more or less 
circular bald areas, but these are white, smooth, and of 
normal texture, and there is no fungus growth in the hair. 
Alopecia from syphilis in its secondary stage resembles 
favus more closely than any other disease of the scalp ; 
but it occurs primarily at a later age than does favus, it 
comes on more suddenly, there is no history of crusts, 
nor cicatricial alteration of the scalp, and there will be 
other evidences of syphilis on the body, and (especially 
in women) the broken arch of the eyebrows. 

Treatment. In the treatment of the disease we need 



FAVUS. 



313 



three weapons — patience, perseverance, and parasiticides. 
Before using the last we should always epilate, pulling 
the hair out systematically from day to day, so that event- 
ually all the hair of the scalp is plucked. To do this 
we may use the epilating forceps (Fig. 38) ; or Kaposi's 

Fig. 38. 




Piffard's epilating forceps. 



method of grasping the hair between the thumb and a 
spatula or piece of stiff cardboard held firmly in the 
hand ; or, in dispensary practice, we may employ epilating 
sticks, made, according to Bulkley, of 



Cerae flavae, 


3ij| 


8 


Laccae in tabulis, 


3iv; 


16 


Picis burgundicae, 


.5x; 


40 


Gummi damar., 


3J ss ; 


48 



M. 



These ingredients are to be melted together, and then 
moulded into sticks a half-inch or more in diameter. 
They are to be used by melting the end, and when warm 
applying it to the hair with a sort of boring motion. 
When cold they are to be suddenly twisted off, when, 
of course, they will bring many hairs with them. The 
" calotte/' or pitch-cap, used to be employed for this 
purpose, but was given up because it caused the death of 
several patients. Kaposi's method is the best of all. If 
the head is greatly crusted, the crusts may be scraped off 
with a curette or cleaned off by means of soaking the scalp 
with oil for a day or two, and then washing with soap and 
water. For an oil we can use sweet oil, sweet almond 
oil, or cotton-seed oil, with 3 per cent, of carbolic or 
salicylic acid. The use of these oils should be continued 
throughout the whole course of the disease to prevent 
the spread of the fungus upon the scalp of the patient and 
to the scalp of other people. After the first washing we 



314 DISEASES OF THE SKIN. 

should allow the scalp to go unwashed for twenty-four 
hours, so as to permit the full action of the parasiticide. 
After the cleansing and the epilation the parasiticide 
must be rubbed and worked into the scalp. Of these 
there are many from which to choose. An ointment 
consisting of a drachm of the crystals of iodine in an 
ounce of goose grease is one of the best. It cannot be 
used over all if the whole scalp is involved, but in sections. 
Sulphur ointment is efficacious, if properly and persist- 
ently used. Other ointments are thymol, naphtol, re- 
sorcin, chrysarobin, and pyrogallol in 5 to 10 per 
cent, strengths, and those of the ammoniate or yellow 
sulphate of mercury. The ointments are to be firmly 
rubbed into the scalp every day after washing with soap 
and water. Or solutions may be employed, as bichloride 
of mercury ; 2 grains to the ounce of ether or alcohol ; 
the oleate of mercury or copper, 10 to 20 per cent. ; tar ; 
oil of cade ; creosote in ether or alcohol ; sulphurous 
acid in full strength ; salicylic acid, 5 per cent, in oil ; 
or tincture of iodine, or resorcin 1 drachm to the ounce 
of lanolin and oil. Iodine, according to Sabouraud, 
should be used only once a month ; in the meantime the 
scalp should be washed alternately with alcohol and 
camphorated alcohol, or with a solution of salol, 1J per 
cent, and kept constantly anointed with iodine ointment. 
After a month the epilation and the iodine are to be 
repeated. Hydronaphtol plaster is said to do good ser- 
vice in favus, used according to the method described 
under Trichophytosis, which see. Peroni 1 recommends 
spraying the head with acetic acid used in an atomizer, 
after covering any excoriated points with diachylon 
ointment on a piece of cloth. At first the scalp feels 
cold. Hyperemia follows which lasts about forty-eight 
hours and disappears, leaving slight desquamation. 
When the hyper semi a lessens the acid is to be again 
used. When there are no excoriations the head is to be 
washed every morning and evening with water and cor- 
iAnn. de derm, et de syph.. 1891, ii., 797. 



FAVUS. 315 

rosive sublimate soap. Busquet 1 recommends sopping 
on daily a solution of 

3 Essentiae cinnamom, £>ijss ; lOf 

Spts. aether, sulph., ad 3J ; ad 39' M. 

Besnier and Doyon 2 recommend as a preparatory treat- 
ment for favus that the hair be cut off from and around 
all the patches, and the whole head covered for two or 
three hours with equal parts of soft-soap and lard. This 
is to be washed off with warm water, and the head is 
to be kept covered during the night with a cap of rubber 
or other impermeable cloth. The next morning the head 
is to be washed perfectly clean, bathed with a solution 
of boric acid (25 : 1000) and covered with borated lint 
soaked in the following solution : 



li Sodii salicylati, 


3iij ; 


12: 


Sodii bicarbonati, 


Sijss ; 


10 


Aquae, 


ad Oij ; 


ad 1000 



M. 

Over all comes the impermeable cap. After a few days 
the dermatitis will disappear and the scalp will be clean 
and then epilation must be practised, the hairs being 
pulled not only from the patches, but for about a half- 
inch about them. Epilation is to be repeated every week 
until no longer any trace of redness about the hairs exists, 
and the head is to be kept covered with the impermeable 
cap. Every evening the whole head is to be rubbed 
with antiparisitic ointment, such as : 

ii Bals. Peruv. vel. 

01. cadini 2 to 5 parts. 



aa 1 to 5 



Ac. salicyl., I 

Pesorcin., j 

Sulph. praecip., 5 to 15 " 

Lanolini. "] 

Vaselini, y aa p. ae ad 100 " M. 

Adepis, j 

1 Ann. de derm, et de syph., 1892, ii., 269. 

2 Kaposi : Mai. de la Peau. French ed., Paris 1891. 



316 DISEASES OF THE SKIN. 

Every morning the whole scalp is washed with tar soap, 
and each favic patch is soaked with the following : 

R 



Alcoholis (90 per cent) 


100 parts. 


Ac. acetic, (crystals),! 


\ to 1 part. 


Acid boric. , 


2 parts. 


Chloroformi, 


5 parts. 



M. 

Then each patch is to be accurately covered with mer- 
curial plaster. 

Epilation is rapidly and painlessly effected by x-rays. 
It is possible to cure a case by this means, but it is better 
to use some antiparasitic after the hairs have fallen. The 
method of using x-rays is the same as in ringworm. 
Kienbock * regards x-rays as the best treatment. He 
recommends the use of a medium tube with a medium in- 
tense light, for fifteen minutes at a distance of 16 to 20 
cm., daily until a dermatitis is caused. 

Favus of the non-hairy parts of the body usually yields 
readily to the removal of the crust and the use of a para- 
siticide. 

Favus of the nail may be treated by the constant appli- 
cation of a mercurial, resorcin, or hydronaphtol plaster. 
If the disease is limited to one or two points, they may be 
cut down upon and the remedy applied directly. Some- 
times it may be necessary to remove the whole nail. 

After a case of favus has been faithfully treated for a 
number of weeks and looks as if it were well, it should be 
let alone and watched carefully for a long time. Any red 
point that appears is evidence that the disease is cropping 
up again, and should be immediately attacked. 

Prognosis. The prognosis is good, provided the case 
is faithfully and energetically treated. Relapses will 
surely occur if any of the fungus remains in the scalp. 
A cure takes months or years to effect. The scars from 
favus are permanent. Favus of the nail is specially re- 
bellious to treatment, and may cause permanent destruc- 
tion of the nail. 

1 Archiv. Dermat. et Syph., 1907, lxxxii., 105. 



FIBROMA. 317 

Feigned Eruptions. See Dermatitis factitea. 

Feuergiirtel. See Zoster. 

Feuermal. See Nsevus. 

Fever Sore. See Herpes facialis. 

Fibroma. Synonyms : Fibroma molluscnm ; Mollus- 
cum fibrosum ; Molluscum simplex ; Molluscum pendu- 
lum ; Recklinghausen's Disease ; Neurofibroma. 

Fibromata are soft tumors of the skin that are com- 
posed of a hyperplasia of the connective tissue as well as 
the subcutaneous tissues, and occur in various shapes, col- 
ors, and sizes. The most commonly encountered form 
of fibroma is 

Molluscum fibrosum. This may be of the color of the 
skin, or pinkish or even brownish or brownish red ; most 
commonly it is of normal skin color. It may be 
rounded, flattened, sessile, or pedunculated, but always 
raised above the level of the skin. It may hang down 
like a polypus. The skin over it feels soft and of normal 
texture, or it may be thickened or atrophied. Hairs 
sometimes grow from it. There may be but one or 
two present, or there may be hundreds of them so that 
the body is strewn over from head to foot with the vari- 
ously shaped tumors. The trunk is the most common 
location for fibromata, but they mav occur on all parts 
and involve even the mucous membranes. (Fig. 39.) 
They give rise to no inconvenience except on account of 
their size, which sometimes may be that of a child's head 
or larger. Their usual size is from that of a cherry to 
that of a walnut. Many of them show a slow growth, 
while many are stationary, and some may undergo invo- 
lution. Comedones of large size may accidentally form 
in some fibromata. The larger ones may ulcerate. All 
of them feel soft, while the larger ones may be elastic to 
the touch. When they hang down in the form of large 
skin -folds which have undergone hypertrophy, the term 
fibroma pendulum is applied to them. Dermatolysis 
(which see) has been considered a form of fibroma. Ac- 



318 



DISEASES OF THE SKIN. 



cording to some authorities, fibrous moles and soft warts 
are but forms of fibroma. 

Scattered among the tumors there may be irregular 
patches of brown pigment, and more or less freckles, 
hairy moles, and vascular nsevi. The skin may be coarse. 



Fig. 39. 




Multiple fibromata. i 

Etiology. Fibromata usually appear in childhood, 
though they may not do so until later in life. They are 
sometimes hereditary, and are often seen in several mem- 



1 From a photograph of a case of Dr. E. T. Tappey, of Detroit. 



FIG WART. 319 

bers of the same family. They tend to increase with ad- 
vancing age — that is, they are not so large or numerous 
in children as in adults. Children with multiple fibro- 
mata are often stunted both physically and mentally. By 
some authorities they are regarded as related to neuro- 
fibromata. 

Pathology. The early tumors and the central por- 
tion of the older growths, consist of embryonic connective 
tissue. The density of the tumors increase toward the 
surface, the larger growths being provided with a firm 
fibrous sheath. 

Diagnosis. Molluscum fibrosum differs from mo//«,s'- 
cum cantagiosum by not having a central depression, and 
by being of the normal color of the skin. They are also 
usually far more numerous. From fatty tumors they dif- 
fer in not being lobulated, and in being pedunculated and 
less flat. Sebaceous cysts are not so numerous, and their 
contents can be squeezed out to a large extent, while fibro- 
mata are solid. 

There is another form 01 fibroma to which the name 
Acrochordon is applied. They occur as small, soft, pedun- 
culated, vascular, and mole-like lesions upon the face, 
shoulders, and elsewhere in elderly people whose skin is 
degenerated. They often take the form of little hernia- 
like sacs of skin when their contents have been absorbed. 

There is also a hard variety of fibromata called des- 
moids. These occur as round or oval, compact, smooth 
nodules, from hemp-seed to pea size. 

Treatment. They may be snipped off with scissors 
or tied off with ligature if pedunculated. If non-pedun- 
culated, they may be destroyed by electrolysis or excised. 
If of large size, they may be excised. The galvano- 
cautery may be used to destroy any form. 

Fibroma Fungoides. See Mycosis fungoides. 
Fibroma Lipomatodes. See Xanthoma. 
Fibromyoma. See Myoma. 
Figwart. See Verruca. 



320 DISEASES OF THE SKIN 

Finnen. See Acne. 

Fischschuppenausschlag. See Ichthyosis. 
Fish-skin Disease. See Ichthyosis. 
Flachenkatarrh der Haut. See Eczema. 
Flachenkrebs. See Epithelioma. 
Flechenmal. See Nsevus pigmentosum. 

Flea-bites occur in the form of small red puncta which 
may or may not be in the centre of wheals. They some- 
times bear a close resemblance to urticaria that has been 
scratched. The grouped arrangement of the lesions and 
the limited areas upon which they occur suggest their 
origin. 

Flesh-worms. See Comedo. 
Fluxus Sebaceus. See Seborrhoea. 

Folliclis. Synonyms: Lupus erythemateux dissemine; 
Folliculites disseminees des parties glabres ; Acne varioli- 
formis of the extremities ; Hydrosadeuite disseminee sup- 
purative ; Necrotising chilblains ; Granuloma innomine ; 
Toxi-tuberculides papulo necrotiques ; Granuloma ne- 
crotica. 

Symptoms. The eruption consists in flattened pin- 
head, rounded papules that develop deep down in the 
derma. They increase in size to that of a lentil. Their 
color is dark red or violaceous. They are firm to the 
touch and surrounded by a red areola. Pustules form on 
top of them, and these dry into crusts which are ad- 
herent, and when removed disclose a small but deep ul- 
ceratiou. Pin-head, pit-like cicatrices are left which may 
have pigmented areolae about them for a time. The 
papules abort sometimes and leave no trace on the skin. 
Their evolution takes four or five weeks, and the lesions 
come out in crops, so that all varieties are present at the 
same time. There is no definite grouping nor subjective 
symptoms excepting, sometimes, tenderness or pruritus. 

The disease affects all parts of the body, but is most 
abundant on the limbs, upon which it commences, espe- 
cially on the hands, feet, elbows, and knees. On the ears 



FOLLICULITIS. 321 

and fingers they appear like chilblains. Sometimes the 
disease is confined to the hands and feet. When the dis- 
ease spreads it does so by continuity. Its spread may 
be continuous or interrupted. It comes out sometimes 
at certain seasons of the year, as spring or autumn. 

Etiolgy. Most cases occur in those who have a poor 
circulation as shown by a dusky blueness of the hands 
and feet, and in children or young people. It is seen 
with lupus, and in those who present evidence of tuber- 
culosis or scrofuloderma. It is described by the French 
as a tuberculide. 

Pathology. It is regarded by some as a granuloma. 
According to Hartzell 1 it begins with inflammatory 
changes in and around the bloodvessels in the deeper por- 
tions of the corium, and gradually extends to the surface. 
There is an abundant round-celled infiltration about the 
vessels with thickening of their walls and obstruction or 
obliteration of their lumina, followed by necrosis of the 
tissue of the corium. Tubercle bacilli have not been 
found in them. 

Diagnosis. Folliclis is allied to acne neerotica. It 
differs from it mainly in location, the latter preferring 
the face. It differs from acne in its distribution, slug- 
gishness, variola-like scars, and absence of comedones. 

Treatment. Crocker advises the application of a 
mercurial plaster before suppuration has occurred. After 
that has occurred the central core is to be removed and 
the pit washed out with a 1 in 40 carbolic acid lotion. 
Everything must be done to improve the general health 
as in tuberculosis, and to stimulate the local circulation. 
Whitfield recommends calcium lactate, and nitroglycerin. 

Folliculitis means an inflammation of the hair follicles. 
When the hairs involved are those of the beard we have 
F. barbcE, or sycosis, which see. The hair follicles on the 
extremities, especially of the legs, may become inflamed 
on account of some irritant applied to the skin. One 



21 



i Med. Rec., 1906, lxix, 1012. 



322 



DISEASES OF THE SKIN. 



form of this is tar acne. In workers in oil or paraffine 
it is no uncommon thing to see each hair on the legs, espe- 
cially the thighs, standing in the centre of a red papule 
or pustule. The cure consists in removing the cause, in 
cleansing the parts, and the application of an alkaline 
soothing lotion. 

Folliculitis Decalvans. Under the name of folliculites 
et peri folliculites decalvantes agminies Brocq has described 

Fig. 40. 




Folliculitis decalvans. 



a form of inflammation of the hair follicle closely allied 
to sycosis. Besnier has given the same disease the name 
of alopecies cicalricielles innominees. It is characterized 
by an inflammatory process, which results in complete 
destruction of the hair papillae, and the formation of cica- 
tricial tissue ; and by a tendency for its lesions to aggre- 



FOLLICULITIS DECALVANS. 323 

gate themselves in groups. Besnier 1 reported a case of 
this in 1889. He says that it is the same thing that has 
been called acne lupoide and folliculite epilante. In the 
case reported the disease affected all the posterior part of 
the scalp, which was sown over with disseminated patches 
of baldness of unequal size, irregular shape, and serpigi- 
nous. They were depressed in the centre, which was 
smooth, polished, thinned, cicatricial, and completely bald. 

Fig. 41. 




Folliculitis decalvans. 



Their borders were not well defined, but merged into the 
islands of healthy hair. The scalp between the borders 
and the centre of the patches was bald, of variegated 
redness, with some hairs broken off at the surface of the 
scalp. In the funnel-shaped openings of the hair folli- 
cles there were little superficial collections of pus. Some 
of the patches were torn by scratching, and others looked 
precisely like those of alopecia areata, without signs of 
inflammation. All treatment seemed to be in vaiu, and 
the scalp bore only the mildest applications. 

1 Ann. de derm, et de sypk., 1889, x., 104. 



324 DISEASES OF THE SKIN. 

Another variety of folliculitis decalvans is that described 
by Quinquaud. It affects most often the scalp hair, more 
rarely that of the beard, pubes, and axillary region. It 
produces irregularity shaped areas of baldness, which are 
quite smooth, polished, pale, atrophic-looking, and pre- 
senting at some points slight redness. The areas are 
disseminated, about the shape of a franc-piece, separated 
by islands of healthy hair. The bald spots are slightly 
depressed. At the peripheries of the patches or in the 
islands of healthy hair between them will be found pin- 
head, discrete pustules about the hairs. The latter are 
easily plucked or fall spontaneously. Or there are simply 
punctiform, isolated red spots which may or may not be 
scaly ; or a red, elevated, inflamed follicle. The fall of 
neighboring hairs produces the bald patches. The disease 
is very chronic and marked by a series of outbreaks. 

Still another form affects the bearded portion of the 
face, and from there invades the temporal region of the 
scalp. This is the ulerythema sycosiforme of Unna, and 
the so-called chronic sycosis. It begins like a sycosis, 
but when the inflammation subsides it is seen that the 
skin is cicatricial and the hair destroyed. There may be 
one or more patches. The patches may be symmetrical, 
or non-symmetrical, and they tend to spread slowly by 
peripheral extension. 

Under the name of Atrophic Alopecia or Pseudo Pelade 
Brocq 1 would separate from alopecia areata and follicu- 
litis decalvans a group of cases to which he gives these 
names, and thus describes them : 

The disease begins insidiously without painful sen- 
sation nor perceptible inflammatory reaction. There 
may be a seborrheal dermatitis, or a slight rosiness, of 
the scalp. Usually the scalp is white, smooth, ivory- 
like. The disease begins most often on the vertex, but 
may begin anywhere. It may begin as a single point or 
at many places at once, the hair falling from them. It 

1 Annal. derm, et syph., 1905, vi., 1. 



FOLLICULITIS DECAL VANS. 



325 



may stop with the production of small bald patches, or 
it may go on to form large ones with satellites. When 
there are a number of small patches on one or more 
regions, it appears cribbled by them. They are white or 
bright rose, smooth, atrophic, from pinhead size to that 
of a twenty-five cent piece. The smaller ones are round 
or oval, the larger ones festooned. If two or more unite 
they form patches irregular in shape. These small patches 
may be entirely concealed by the long hair. 

Fig. 42. 




Pseudo Pelade (Brocq.) 

By the uniting of smaller patches large ones may form 
with polycyclique contours, and small patches separated 
from them by zones of hair. Band-shaped patches may be 
formed. At the edge of the scalp there is always a border 
of sound hair 1 to 3 cm. wide. The affected parts of the 
scalp are thinned, atrophied, and depressed ; smooth and 
soft, or lardaceous and succulent. There may be epider- 
mic cones deep in the follicles after the disappearance of 
the hair. The hair in and about the patches may show 
no change, or signs of folliculitis. When the hair falls 
all signs of inflammation ceases. There may be an 



326 



DISEASES OF THE SKIN. 



erythematous zone about the patches. There are no 
broken-off hairs in the patches, nor exclamation-point 
hairs. The beard may be affected. 

The course of the disease is very slow, though it may 
be rapid at first. There are lengthy pauses in its pro- 
gress followed by rapid advances. Though there may 
be many patches there never is complete baldness. It 
occurs as a complication of many dermatoses such as se- 
borrheal dermatitis, keratosis follicular is, and lichen scro- 
fulosorum. 

Pig. 43. 





y--- : ; ■ . .^ 












Si 







Pseudo Pelade (Brocq.) 

Etiology. This is a rare disease that affects adults, 
more commonly men. The youngest reported case was a 
fourteen-year-old girl. Though the disease is probably 
parasitic, thus far no organism has been demonstrated. 

Pseudo Pelade occurs in adults between twenty and 
forty years old. It is about four times more frequent in 
men than in women, and in those with dark, coarse hair. 
Nervous, mental and physical weakness seem to play a 
part in its causation, but nothing definite is known about 
the etiology of the disease. 



FORDYCE'S DISEASE OF THE LIPS. 327 

Diagnosis. It differs from trichophytosis and favus 
in not having their fungi in the hair. The absence of 
sulphur-yellow cupped crusts further distinguishes it from 
favus. It differs from alopecia areata in not having 
exclamation-point hairs, in its causing permanent atro- 
phy, and in the multiplicity of small patches. 

Treatment. Epilation of loose hair, and the appli- 
cation of sulphur or mercurial ointments are to be advised. 
Others recommend resorcin, salicylic acid, boric acid, 
and mercurial applications. 

Prognosis. If taken early enough it may be checked. 
When atrophy has occurred it is permanent. 

Folliculitis, Depilating, of the Limbs. We owe our 
knowledge of this disease to Arnozan and Dubreuilh. It 
is a rare affection of the legs and thighs. It is symmetri- 
cal. It begins as red papules, from millet seed to pea size, 
pierced by a hair. This is soon surmounted by a pustule 
that dries into a crust. After some weeks the papule 
becomes absorbed, the hair falls, and a small pigmented 
cicatrix is left. The disease occurs in patches surrounded 
by an irregular and ill-defined zone of folliculitis in pro- 
cess of development. It is chronic in its course, occurs 
usually in middle-aged men, and arises without known 
cause. Treatment has thus far been without effect. 

Folliculitis Disseminees des Parties Glabres. See Fol- 
liclis. 

Follilculitis Rubra. See Keratosis pilaris. 

Fordyce's Disease of the Lips. In 1896 J. A. Fordyce 1 
first called attention to this disease, which is probably not 
very rare, as a number of cases have been reported since 
then. It affects the mucous membranes of the lips in the 
form of patches made up of small, irregular, closely ag- 
gregated milium-like bodies of light-yellow color, located 
just beneath the mucous membrane. The same bodies are 
also scattered disseminately about the patches. Burning 

1 Jour. Cutan. and Gen.-Urin. Dis., 1896, xiv., 413. 



328 DISEASES OF THE SKIN. 

and itching, and a feeling of tension as if the lip were 
swollen, are complained of. Similar lesions occur on the 
inside of the cheeks along the line of the closed teeth. 
These are somewhat lighter in color, more elevated and 
papillomatous. The milium-like bodies can be removed 
readily. They may be found in several members of the 
same family, and increase with age. They are atrophic 
sebaceous glands in the mucous membrane. 

Fragilitas Crinium. See Atrophia pilorum propria. 
Frambcesia. See Yaws and Dermatitis papillaris cap- 
illitii. 

Freckles. See Lentigo. 
Frieselausschlag. See Miliaria. 
Frostbite. See Dermatitis calorica. 

Fungous Foot of India. Synonyms : Madura foot ; 
Mycetoma ; Podelcoma ; Ulcus grave ; Tubercular dis- 
ease of the foot. 

This is a disease that is endemic in certain parts of 
India, but has been met with in this country. Though 
usually affecting the foot and leg, it is seen occasionally 
on the hands, shoulders and scrotum. According to 
Crocker, there are three varieties, the pale, the black, 
and the red, the latter being very rare. It may begin 
with slight congestion of the affected part ; or as a local 
induration, either superficial or deeply seated, of some 
part of the foot, which is firmer, larger, more diffused, 
and less painful than a boil. When this is opened, it 
discharges pus at first, later granules like poppy seeds, or 
mulberry-like masses are mingled with the discharge. Or 
it may begin as a blackish or bluish mottled discoloration 
like tattoo puncta. The progress of the disease is slow, 
but in the course of a few years the foot becomes swollen 
and distorted, the arch being broken, the toes being over- 
extended, and the sole convex from behind forward. It 
becomes dotted over with the raised orifices of sinuses 
extending deep down into the tissues, and giving vent 
to the above-described discharge. 



FURTJNCULUS. 329 

It is more coimnon in males than in females, and in 
those who work barefoot, and is rare before puberty. 
Its origin is obscure, though it is supposed to be due to 
a fungus, perhaps to more than one. It is said by Op- 
penheim that the pale variety is caused by an actino- 
mycosis, and the black variety by an oidium or mold 
fungus. Surgical interference is the only hope for a 
cure. 

Furunculi Atonici. See Erythyma. 

Furunculus. Synonyms : (Fr.) Furoncle, Clou ; (Ger.) 
Blutschwar ; Furuncle or Boil. 

An acute circumscribed phlegmonous inflammation 
around a skin gland or hair follicle, characterized by one 
or more round, more or less acuminated, firm, painful 
formations, and usually terminating by necrosis and sup- 
puration. (Foster.) 

Symptoms. This is a common and familiar disease of 
the skin. Its most frequent locations are the back of 
the neck, face, forearms, buttocks, and legs, though it may 
occur anywhere. It begins as a small, round, red, pain- 
ful spot, which in two or three days enlarges to attain the 
size of a split pea or silver quarter- or half-dollar. It 
is now raised above the surface, hard, of a dark-red color 
at the centre with the redness fading away into the sound 
skin, more or less pyramidal in shape, exquisitely tender 
to the touch, and with a most agonizing throbbing pain. 
Its centre soon becomes yellow, indicating the point at 
which suppuration has taken place, and where it will 
open. From the opening comes the "core," a greenish- 
gray or whitish pultaceous mass mixed with pus and 
blood. With the escape of this all the symptoms subside 
and the cavity fills up by granulation, leaving more or 
less of a scar. The course of the individual boil is from 
seven to ten or fifteen days. At times suppuration does 
not take place, but the mass undergoes resolution. This 
is the so-called " blind boil." Any boil may leave in 

1 Archiv f. Derm. u. Syph., 1904, lxxi., 209. 



330 DISEASES OF THE SKIN. 

the skin a thickened, indurated mass that slowly under- 
goes absorption. 

There may be but one boil or there may be dozens of 
them. They come out in crops of from two to half a 
dozen at a time. If very numerous, or of large size, 
they give rise to constitutional disturbance. They may 
continue to form for weeks, months, or even years, if left 
untreated. This is what is called furunculosis. 

Boils are always isolated. They may be confined to 
one locality or come out in a number of regions at the 
same time. There may be sympathetic enlargement of 
the neighboring lymphatic glands. If the disease is ex- 
tensive, the patient presents a truly pitiable condition. 

If a boil starts from a sweat gland, it resembles that 
which originates in a sebaceous gland, except, according 
to Crocker, it has no mattery head and is somewhat less 
indurated. This form of boil is called hydradenitis by 
Verneuil and Bazin. It is of the size of a pea, and is 
most often met with in the axillae, about the anus and 
perineum, near the nipples, and may form anywhere 
Avhere there are sweat glands, excepting on the soles of 
the feet. 

Boils may occur in the external auditory canal in con- 
junction with the disease elsewhere. They are exceed- 
ingly painful and produce deafness. One or both ears 
may be affected, but usually it is only one ear. They 
may set up inflammation of the entire canal and tympa- 
num ; one case of this sort has ended fatally. If the 
furuncle is situated in the posterior wall of the canal, or 
a general inflammation has been set up, considerable 
redness and tumefaction over the mastoid region may 
occur. (Dr. A. Rupp. 1 ) 

Etiology. The cause of furuncles is the entrance 
into the skin of the staphylococcus pyogenes aureus et 
albus. Local infection produces crops of boils occurring 
in one regiou, and the doctrine of local infection finds 
further support in the results of treatment by antiseptics. 
1 Personally communicated. 



FURUNCULVS. 331 

It must be remembered that these micrococci are widely 
distributed, having been found in dishwater, in the super- 
ficial layers of decayed vegetable matter, in the swaddling- 
clothes of healthy infants, in the dirt under the finger-nails, 
and in numerous other places. Like other parasites, 
these require some peculiarity of soil for their growth, or 
at least an opportunity for gaining entrance to the gland- 
ular apparatus of the skin. The soil is afforded in lowered 
vitality of the skin, and thus Ave find boils in diabetes 
mellitus, after specific fevers, in anaemia, lithaemia, uraemia, 
and septicaemia ; and as a complication of other skin dis- 
eases, such as eczema, prurigo, lichen tropicus, and sca- 
bies. In many, perhaps in most cases, no disorder of the 
general health can be discovered. The second condition 
is fulfilled by local injury to the skin, such as friction or 
pressure, or scratching. Boils are contagious, as well as 
auto-inoculable, and can be produced by inoculation of 
pure cultures of the micrococcus. The popular notion 
of their origin from too good living or from beiug run 
down is only another way of saying that they occur in 
individuals not in perfect health. 

Pathology. The inflammation begins in the corium 
and deeper tissues in or about the hair follicles or glands 
of the skin. "The mechanism of the process is supposed 
by some to be that the vessels around the gland or follicle 
become blocked, producing its death, and inflammation is 
then set up around the necrosed tissue to get rid of it by 
suppuration. (Crocker. ) 

Diagnosis. The disease is so common that there is no 
need for detailing the diagnosis. For the diagnosis from 
carbuncle, see under that word. 

Treatment. In most cases there is no need of inter- 
nal treatment. If the patient is out of health in any way, 
we should endeavor to help him back to his normal con- 
dition. In furuuculosis we should always bear in mind 
the probability of there being diabetes mellitus at the 
bottom of the mischief, seek for it, and do our best to 
cure the patient if we find evidence of it. There are 



332 DISEASES OF THE SKIN. 

many drugs recommended for the treatment of boils, 
apart from constitutional conditions. Of these, sulphide 
of calcium is one of the most popular, y 1 ^ of a grain being 
given every two or three hours, or a J to J grain three 
or four times a day. It is of doubtful efficacy. Piffard 
speaks well of the compound syrup of the hypophos- 
phiteSy a dessertspoonful three times a day. Hardy 
recommends tar-water up to a quart a day. The sulphite 
or hyposulphite of sodium in 15 to 20-grain doses three 
times a day is also well spoken of. Yeast is a homely 
but sometimes efficient remedy, either a J wineglass- 
ful being taken night and morning, or a like quantity in 
divided doses, or one of Fleischmann's yeast cakes being 
eaten during the day. Le Gendre, 1 believing that boils 
may arise from the absorption of products of imperfect 
digestion, advises the disinfection of the intestinal tract 
by the use of the following powder : 



& /3-Naphtol, -| 

Bismuth, salicylat., \ aa gr. ivss 

Magnesia carb., J 



30 



M. 



which is to be given every four hours. 

The most recent method of internal treatment is by 
opsonins, Whitfield gives Wright's method as follows : 
He injects from 500 to 2000 millions of staphylococci 
pyogenes aureus et albus suspended in normal salt solu- 
tion previously heated to 60° C. This is to be re- 
peated in a week. The injections cause some local tender- 
ness lasting twenty-four hours, and some slight malaise. 
The treatment is said to be effective. It certainly is 
troublesome and requires a laboratory close at hand. 

The local treatment of boils is important and efficient. 
They should not be poulticed, as, being due to a fungus, 
the heat and moisture only facilitate the growth of the 
same and the production of new boils. That new boils 
are apt to spring up about a poulticed boil is a common 
experience, and for this reason. If it is deemed advis- 

i Union med., 1888. xlv., 98. 



FURUNCULUS. 333 

able to obtain the relief and comfort that a poultice un- 
doubtedly gives, hot compresses of boric acid should be 
used. We should endeavor to abort the development 
of a boil. To do this there are various approved 
methods, but the one most highly commended is the 
use of carbolic acid. This may be either by touching 
them with pure carbolic acid ; injecting them with a few 
drops of a 2 per cent, solution ; or spraying them with 
the same solution for fifteen minutes at a time eight times 
during the day, and keeping them covered with carbolized 
dressings in the meantime. Ilurcury may be used instead 
of carbolic acid, the boils being kept covered with emplas- 
trum hydrarg. with a little hole cut in the plaster to cor- 
respond to the centre of each boil ; or an ointment of the 
nitrate or red oxide may be used. Painting with iodine 
is also commended ; as well as keeping them covered with 
a saturated solution of boric acid, or an 8 or 10 per cent, 
plaster or ointment of salicylic acid. Hardaway speaks 
highly of Unna's carbolic acid and mercury mull plaster. 
Electrolysis to destroy the follicle is spoken of by the 
same authority. 

When aborting is out of the question, it is a good plan 
to thrust a little pure carbolic acid, on the sharpened end 
of a wooden toothpick, or the like, into the central open- 
ing. It hurts for a few minutes only, and is promptly 
curative. The boil should then be dressed with carbolized 
vaseline or a boric acid ointment, or a 5 per cent, salicylic 
acid ointment or oil should be smeared over the boil and 
the contiguous parts. Many years experience has con- 
vinced me that this is the treatment for boils, and when 
properly carried out it rarely fails to cure. Or it may 
be opened and dressed with iodoform, or aristol, as the 
odor of the former is objectionable. Here too the mull 
plaster of carbolic acid and mercury may be used. Instead 
of the pure carbolic acid, Crocker advises the glycerole 
of carbolic acid of the British Pharmacopoeia. For 
some time after the boils are apparently cured it is well 
to bathe the back of the neck daily with a saturated 



334 DISEASES OF THE SKIN. 

solution of boric acid, if that has been the site of infec- 
tion. 

Furuncles of the ear. My friend, Dr. A. Rupp, late 
aural surgeon to the New York Eye and Ear Infirmary, 
has kindly advised me on this head as follows : In the 
treatment of furuncles of the external auditory canal the 
first requisite is that the physician sees that which he is 
to treat. If the auditory canal be filled or unclean, it 
must be syringed out with a 2 to 5 per cent, solution of 
carbolic acid, followed by a solution of bicarbonate of 
soda as hot as can be comfortably borne. 

The canal is to be dried with absorbent cotton, and if 
the membrana tympani is intact filled with 



aa30 



Hydrarg. bichlor., 


gr. v; 


Glycerini, ") 
Alcoholis, J 


aa gj- 



M. 



which is to remain in some minutes, and then the excess 
is allowed to drain off. The canal is lightly closed with 
borated or salicylated absorbent cotton. Protargol, 5 
grains to the ounce of water, applied on pledgets of ab- 
sorbent cotton and left in for an hour or two, gives good 
results. If the membrana tympani is deficient, the whole 
canal is to be filled with powdered boric acid and the 
orifice closed as before. In either case the cotton is to be 
changed when soiled. When furuncles are at the inner 
end of the canal near the membrana tympani, a leech or 
two in front and a little above the tragus will afford 
much relief. It is unnecessary to incise the furuncles 
except where pus has formed and has no outlet. 

Prognosis. In most cases boils are annoying, but not 
dangerous. Those about the face give the most trouble. 
How long new boils will continue to form it is impossible 
to say. If the treatment by carbolic acid is used, the dis- 
ease is usually soon over. In furunculosis all will de- 
pend upon how soon we can get the patient into a better 
physical condition. 

Furunculus Orientalis. See Aleppo boil. 



GRANULOMA ANNULARE. 335 

Gale. See Scabies. 

Gangrene of the Skin. See Dermatitis gangrenosa. 

Gansehaut. See Cutis anserina. 

Gefassmal. See Nsevus vasculosus. 

German Measles. See Rubeola. 

Geromorphisme Cutane is the name chosen by Drs. Sou- 
ques and Charot 1 to designate an affection that pro- 
duced changes in the skin of a girl eleven years of age so 
that she looked like an old woman. The expression of 
the face suggested that due to facial paralysis. The skin 
hung in loose folds, and was flabby like the skin some- 
times seen in very old people. Apart from loss of natural 
consistence and elasticity there was no change in the skin. 
If lifted up, twisted, or folded in any way, it returned 
very slowly to its normal position ; and it was abnormally 
movable over the subcutaneous tissues, in these things 
suggesting that form of dermatolysis called " elastic skin." 
There were no changes in the hair, nails, or teeth. There 
was no assignable cause for the condition, which was pre- 
served unaltered during an interval of ten years from the 
first to the last time that the doctors saw the case. 

Glanders. See Equinia. 
Glanzhaut. See Atrophoderma idiopathica. 
Glossy Skin. See Atrophoderma idiopathica. 
Gneis. See Seborrhoea sicca. 
Gommes Scrofuleuses. See Scrofuloderma. 
Goose-flesh. See Cutis anserina. 

Granulationsgeschwiilste. Connective-tissue new 
growths. 

Granuloma Annulare is the name given by Crocker 2 to a 
disease that consists in the eruption of a number of vio- 
laceous, red, or pale, firm, warty or flat nodules of slow 
development that tend to form circles by aggregation or 
partial coalescence, leaving the compound nodules visible. 
Involution takes place slowly, leaving broken circles, 

1 Nouvelle Icongraphie de la Saltpgtridre. 

2 Brit. Journ. Dermat., 1902, xiv., 1. 



336 DISEASES OF THE SKIN. 

crescents, or gyrate patches. Around them there may be a 
narrow areola. They tend to occur over bony prominences, 
such as the knuckles, and wrists, and on the neck, upper 
part of the face, and over the knees. There are no subjec- 
tive symptoms. In some cases there is a history of tuber- 
culosis in the family. Clinically and histologically they 
correspond to granulomata. 

Granuloma Fungoides. See Mycosis fungoi'des. 
Granuloma Necrotica. See Folliclis. 

Granuloma Pyogeticum. This is a tumor consisting of 
granulation tissue. " Proud flesh " is of this nature. It is 
seen about wounds, such as that caused by vaccination. 
It is probable that there is some specific germ to cause the 
growth of these exuberant granulations. It sometimes 
takes the form of a raspberry. The application of nitrate 
of silver, tincture of iodine, or some antiseptic powder to 
it will cause it to flatten down speedily. 

Granulosis Rubra Nasi is a disease of the nose of chil- 
dren, first described by J. Jadassohn. 1 The cartilaginous 
part of the nose is more or less red, the redness not being 
sharply defined. It sometimes spreads to the cheeks and 
upper lip. Upon the red base are isolated, dark-red 
papules which may be very small and scarcely elevated, 
or pin -head size and prominent. They are pointed, non- 
confluent, and apparently located about the follicle mouths. 
They pale on pressure. Occasionally small vesicles or 
pustules appear that soon dry up. The nose is generally 
cold to the touch. There may be telangiectases. There 
is no scaling. Hyperidrosis of the nose or of the whole 
face is a constant factor. The disease grows better and 
worse, at times disappearing, but it does not change with 
the weather. Most of the cases occur in children from 
seven to sixteen years old who are not robust. It is very 
persistent, lasting for years, sometimes into adult life, 
though the disease tends to disappear at the time of 
puberty. Pathologically, it is a chronic inflammation 
1 Archiv Derm. u. Syph., 1901, lviii., 145. 



GUINEA- WORM DISEASE. S3 7 

about the mouth of the sweat ducts. Treatment is una- 
vailing. 

Grayness. See Canities. 

Greisenhaftigheit der Kinder. See Sclerema neonato- 
rum. 

Grocer's Itch is eczema of the hand. 
Grubs. See Comedo. 
Grutum. See Milium. 
Grutzgeschwulst. See Atheroma. 

Guinea-worm Disease, or Dracontiasis, is met with en- 
demically in tropical climates. It is caused by the larvae 
of the guinea-worm, or filaria medinensis, being swal- 
lowed, and developing in the body. It is possible that the 
worm may gain access through a traumatism. The female 
makes its way into the muscles, and within nine or twelve 
months gives rise to the symptoms of the disease. The 
male probably dies and is passed out of the body. The 
symptoms of the disease are a small tumor under the skin 
that feels like a coil of soft string ; the appearance of a pea- 
to filbert-sized vesicle upon this when the animal is about 
to escape ; tension, pain, and itching ; in severe cases in- 
flammation, purulent discharge, hectic fever, and perhaps 
delirium. The worm is either gradually wholly extruded 
after the vesicle breaks, or a new tumor forms after a 
part has escaped, and this after a time breaks and the rest 
of the worm comes away. There may be only one worm 
or a legion of them. They are located most often in the 
foot, but may be found anywhere. 

Treatment. The treatment of the disease is to re- 
move the worm, which is done by winding it carefully 
around a stick when the head is protruded, giving a turn 
or two every day until the worm is extracted. Manson 
advises against this, and speaks well of injecting into the 
tumors a 1 to 1000 solution of bichloride of mercury. 
This kills the worm, and it can then be removed. Tinc- 
ture of asafoetida in doses of 1 or 2 drachms three times 
a day kills the worm before extraction, 
22 



338 DISEASES OF THE SKIN. 

Gumma. See Syphilis. 

Gune. See Tinea imbricata. 

Gurtelkrankheit. See Zoster. 

Gutta Rosea. See Rosacea. 

Haarmenschen. See Hypertrichosis. 

Haematidrosis, or Haemidrosis, is a rare disease of the 
sweat glands in which, on account of an effusion of blood 
into the coils and their ducts by diapedesis from the sur- 
rounding vascular plexus, blood is discharged upon the 
skin along with the sweat. The subjects are apt to be 
hysterical young women, though the affection has been 
seen in newborn children. It is in some cases vicarious 
menstruation. The points of election are the face, ear, 
umbilicus, hands, and feet. Ephidrosis cruenta and 
bleeding stigmata are other names for the curious malady. 
The treatment should be directed to the condition of the 
individual. 

Haemorrhoea Petechialis. See Purpura. 

Hair, Discolorations of. Hair sometimes falls out to 
grow in of a different color. The continuous hypodermic 
administration of pilocarpine has been followed by a 
change of color of the hair from light to dark. Green 
hair occurs in workers in copper; blue hair occurs in 
workers in cobalt and indigo. These colors can be re- 
moved by washing. Yellow hair is occasionally seen in 
icterus. Various chemicals bleach the hair, such as per- 
oxide of hydrogen. Chrysarobin stains it purple ; resorcin 
may stain it green. Bicarbonate of soda changes dark 
hair to a dirty brown. 

Harlequin Foetus. See Ichthyosis congenita. 
Hautfinne. See Acne. 
Hauthorn. See Cornu cutaneum. 
Hautgries. See Milium. 
Hautkrebs. See Epithelioma, 
Hautsclerem. See Scleroderma. 
Hautwtirmer. See Comedo. 
Haemorrhage, Cutaneous. See Purpura. 



HERPES. 339 

Haematrophia Facialis. See Atrophoderma idiopathica. 
Henoch's Disease. See Purpura fulminans. 

Herpes. An acute inflammatory disease of the skin 
characterized by an eruption of one or more groups of 
vesicles upon reddened bases. 

There are two main varieties of the disease : one occur- 

Fm. 44. 





Herpes febrilis. 

ring upon the face, herpes facialis, and one occurring 
upon the genitals, herpes progenitalis. 

Symptoms. Herpes facialis, also called herpes febrilis, 
herpes labialis, hydroa febrilis, fever blister, or cold sore, 
usually occurs upon the lower part of the face, about the 
mouth (Fig. 44). There is commonly some slight dis- 
turbance of the general economy, not as part of the dis- 



340 DISEASES OF THE SKIN. 

ease, but as the cause of it. The patieut first notices 
more or less marked burning, stinging, or itching in the 
part, and perhaps at the same time erythematous papules 
may form. After a few hours a number of piuhead- to 
pea-sized, clear, fully distended vesicles will appear upon 
an erythematous base. Perhaps the herpetic patch may 
appear suddenly without antecedeut erythema. There is 
usually not more than one or two patches of small size. 
There may be a score or more of them, and they may be 
of large size. The patches are always irregular in shape. 
There may be but two or three vesicles in a group, or 
there may be a dozen of them. They do not tend to 
break down of themselves, but after a few days dry up 
into a crust which falls and leaves a red spot that soon 
disappears. Sometimes the vesicles may coalesce into 
bullae, the covers of which may fall and a superficial 
ulceration be left. The duration of the disease is about 
eight or ten days. The most common location is upon 
the upper lip, but it may be anywhere upon the face, 
and not uncommonly the groups develop bilaterally. The 
mucous membrane of the mouth may also be involved, 
but here, owing to the heat and moisture, the vesicles are 
seldom seen, as they break down and leave excoriated 
points. There is a strong tendency for the disease to 
recur with the recurrence of the exciting cause. In some 
cases it recurs at irregular intervals for months and with- 
out apparent cause. 

Herpes may occur on any part of the body and pre- 
sent the same symptoms as when it occurs on the face. 

Etiology. It is still an undetermined question whether 
herpes facialis is a zoster or not. By most authorities it 
is considered to be an independent disease ; by a few it is 
thought to be an incomplete zoster. It is known to occur 
with catarrhal inflammations of mucous membranes, such 
as a coryza, bronchitis, or pneumonia; with digestive de- 
rangement, as gastritis or enteritis; with various febrile 
diseases such as malaria; and it is very often seen in 
women as a herald of the menstrual epoch, occurring 



HERPES. 341 

with great regularity for years. It arises sometimes on 
account of an injury to the terminal ends of the nerves, 
and, as such injuries are liable to occur in the tender 
mucous membrane of the lips, this may be an explanation 
of its frequency about the mouth. Infection has been 
invoked by a few observers as a cause, but this is not 
proven. It is evidently a neurosis, and in some cases 
no cause for it can be found excepting nerve disturbance. 
Sometimes it occurs coincidentlv with herpes progeni- 
talis or with zoster. 

Diagnosis. It must be diagnosticated from zoster and 
from vesicular eczema. From zoster it differs in not oc- 
curring in a series of groups scattered along the course of 
distribution of the trigeminus ; and in frequently being 
bilateral. Generally speaking, there is more marked 
neuralgia in zoster, though in some cases this is wanting 
From eczema it differs in the large size of its vesicles, in 
their showing no tendency to break down, in being less 
pruriginous, in running a regular course, and in rapidly 
recovering by the simple drying up of the vesicles. 

Treatment. Left to itself the disease will speedily 
get well, and really requires no treatment beyond protec- 
tion with flexible collodion or any indifferent soothing 
lotion or ointment. We are often asked if we cannot 
prevent or abort the disease when due to the menstrual 
flux. Women well know that the application of spirits 
of camphor will sometimes do this. Hardaway recom- 
mends rubbing the parts with borax. One of the alco- 
holic solutions recommended by Leloir for this purpose in 
herpes progenitalis may be used, namely, either 2 per 
cent, resorcin ; 1 per cent, thymol ; 3 per cent, men- 
thol, or 2 per cent, tannin frequently applied. 

Herpes progenitalis. This has been called herpes pre- 
putial is, but as it occurs in women as well as men and 
on other places than the prepuce, the name is obviously 
incorrect. 

Symptoms. The eruption is preceded and accompanied 
by burning and itching, and the vesicles occur in groups 



342 DISEASES OF THE SKIN 

upon aii erythematous base. If on the prepuce, that part 
is sometimes swollen. The vesicles are at first clear with 
serous contents, and if on moist locations, as under the 
prepuce or about the mucous membranes of the female 
genitals, they soon break down and leave tiny excoria- 
tions. There may be but one or several patches of herpes. 
The disease runs a course of eight or ten days and gets 
well of itself, unless irritated under the mistaken idea of 
its being a soft sore, chancroid. 

According to Bergh, 1 who has made a careful study of 
the disease, in women the groups usually contain five to 
eight pinhead- to hemp-seed-sized vesicles, but may have 
twenty to thirty-five millet- to poppy-seed-sized vesicles. 
Around each group is a reddish areola. The vesicles are 
isolated, and seldom confluent. Itching is apt to precede 
their outbreak. There may also be slight tenderness or 
swelling of the neighboring glands. In both sexes the 
patches may be unilateral, bilateral, or median. In men 
it occurs most frequently on the inner surface of the 
prepuce, then on its outer surface, the sulcus, glans, 
sheath of the penis, and rarely in the meatus. In women, 
Bergh found it most often on the labia majora, then the 
labia minora, and genito-anal region ; seldom on the clitoris 
or in the vestibule ; very rarely on the cervix uteri. The 
disease has a tendency to relapse, in men with each coitus, 
in women with each menstrual period. It is common- in 
women to have herpes of the face at the same time, and 
this has been noted in men. In women herpes facialis 
may occur with one menstruation, and herpes progenitalis 
with another. 

Etiology. The cause of the disease is congestion of 
the genital region. Thus in men it is frequently seen two 
or three days after each coitus ; or accompanying a gonor- 
rhoea or chancroid. A long prepuce seems to predispose 
to it. In women it comes in 80 per cent, of the cases 
with menstruation (Bergh), and in them it does not seem 
to have any marked relation to the sexual act. It is also 

1 Manatshefte . prakt. Dermat., 1890, x., 1. 
f 



HERPES. 343 

seen in connection with pregnancy and the puerperal state, 
as well as in gout, constipation, and digestive disorders. 
It is a not infrequent disease. Greenough 1 met with it 
in men in about 17 per cent, of all venereal cases in 
private practice. In women there are no statistics from 
private practice, and, indeed, it is in this country but 
rarely reported. Both Bergh and Unna, however, met 
with it very frequently in public prostitutes in St. Peters- 
burg and Hamburg. 

Diagnosis. The disease of itself is of little moment, 
but is of great consequence viewed from a diagnostic stand- 
point on account of its liability to be taken for chancroid 
or for the initial lesion of syphilis. This can hardly occur 
if the vesicles are seen, but when they are no longer pres- 
ent some difficulty may arise. From chancroid the super- 
ficial character of the lesions and their grouping point to 
herpes. In case of doubt the use of a simple dusting 
powder for a day or two will clear up the difficulty, be- 
cause the chancroid will continue to enlarge while the her- 
pes will become well. Auto-inoculation will afford positive 
evidence. From the initial lesion of syphilis herpes dif- 
fers in the absence of all induration of its base and in the 
inflammatory character of the lesion. Here again a short 
wait w T ill clear up the diagnosis. 

Treatment. Herpes progenitalis will usually promptly 
disappear by the use of a dusting powder of bismuth, or 
oxide of zinc and starch ; or by covering it with a piece of 
lint soaked in an astringent solution, such as a weak lotion 
of liquor plumbi subacetatis. If suppuration has occurred 
on account of bad treatment, and the glands are enlarged 
or tender, the patient had best be put in bed. Circum- 
cision has been recommended to prevent recurrences, but 
is of doubtful efficacy. It is well to have the patient wash 
the parts daily and after coitus. Marriage and fidelity to 
the wife are good means of curing a relapsing herpes. 
Astringent washes are useful in both sexes. If the 
"habit" of herpes progenitalis, as it may be termed, has 
1 Arch. Dermat., 1881, vii., 1. 



344 DISEASES OF THE SKIN. 

been formed, careful hygienic and general treatment may 
be necessary for a cure. Leloir's directions, as given 
under Herpes facialis, may be tried for aborting the disease. 

Herpes Circinatus is either erythema iris or trichophytosis 
corporis. 

Herpes Circinatus Bullosus was the name given by Wilson 
to what has since been called Herpes gestationis. 

Herpes Cretace. See Lupus erythematosus. 
Herpes Esthiomenes. See Lupus vulgaris. 

Herpes Gestationis is regarded as being a dermatitis her- 
petiformis occurring during and provoked by pregnancy. 
It is prone to relapse with each succeeding pregnancy ; 
and slowly subsides after delivery. Apart from its etio- 
logical relation, it corresponds closely to dermatitis herpe- 
tiformis, which see. 

Herpes Imbricuie. See Trichophytosis corporis. 

Herpes Iris. See Erythema iris. 

Herpes Parasitaires. See Trichophytosis corporis. 

Herpes Phlyctaenoides. See Zoster. 

Herpes Tonsurans, sen Tonsurant. See Trichophytosis 
capitis. 

Herpes Tonsurans Maculosus. See Pityriasis rosea. 

Herpes Zoster. See Zoster. 

Herpetide Maligne Exfoliative. See Dermatitis exfolia- 
tiva. 

Herpetide. This is a class of skin disease which de- 
pends upon what the French writers call the herpetic 
diathesis. The affections in this class are marked by 
long duration, obstinacy to treatment, tendency to relapse, 
and more or less pain and discomfort. Under it are 
included eczema, the lichens, psoriasis, and prurigo. 

Hidrocy stoma. This disease was formerly regarded as 
a pompholyx of the face, but Robinson x has shown that 
it is a separate affection. 

1 Jour. Cutan. and Gen.-Urin. Dis, 1893, xi., 293. 



HIDROCYSTOMA. 



345 



Symptoms. The eruption occurs upon the face in the 
form of a large number of discrete, disseminated, tense, 
clear, watery, boiled-sago-grain-like vesicles. In size they 
vary from that of a pinhead to that of a pea. In color 
they may be light yellow, of a bluish tint, or white. If 



Fi°r. 45. 





Hidrocystoma. 



pricked, a drop of clear acid fluid escapes. They are 
obtuse, round, or ovoid. If they are present in great 
numbers, they may crowd closely together, but do not 
coalesce. There is no sign of inflammation about them, 
and no subjective symptoms arise from them, excepting, 



346 DISEASES OF THE SKIN. 

at times, a feeling of tension or smarting that is not pro- 
nounced. After lasting several weeks they dry up and 
disappear, while new ones appear. The disease is always 
most pronounced in hot weather, and may disappear en- 
tirely in winter. 

The eruption is usually seen upon the lower part of the 
forehead, the orbital region, nose, cheeks, lips, and chin 
— that is, upon the middle regions of the face. 

Etiology. The disease occurs most often in women, 
and especially in washerwomen. It occurs also in men. 
It is a disease of adult life, which is favored by warmth 
and moisture. As it occurs but rarely, and is an acquired 
disease there must be some yet undiscovered cause for it. 

Pathology. The secreting portion of some of the 
sweat glands has an enlarged lumen from dilatation of the 
tube and contraction or compression of the epithelial cells 
against the basement-membrane, the lumen being filled 
with liquid, and a granular material resembling that 
usually seen in normal glands, but in increased amount. 
With the exceptions of those thus affected, the excretory 
apparatus is normal. (Robinson.) 

Treatment. As far as possible the patient must 
avoid everything that will cause sweating. The indi-, 
vidual lesions must be punctured. 

Hirsuties. See Hypertrichosis. 
Hives. See Urticaria. 

Homines Pilosi, seu Sylvestris. See Hypertrichosis. 
Honeycomb Ringworm. See Favus. 
Horn. See Cornu cutaneum. 
Hiihnerauge. See Clavus. 

Hyalome Cutane. See Colloid degeneration of the skin. 
Hydrosadenitis Suppurativa Destruens. See Folliclis. 
Hydradenomas Eruptifs. See Adenoma of sweet glands 
and epithelioma, multiple benign cystic. 

Hydroa is practically dermatitis herpetiformis. It is an 
old term recently revived, and is of uncertain significance. 



HYDROA VACCINIFORME. 347 

By some it is used to designate eruptions that are midway 
between erythema multiforme and pemphigus. 

Hydroa Bulleux. See Erythema iris. 

Hydroa Vacciniforme. Hutchinson, under the name of 
" Recurrent Summer Eruption/' Unna under the name 
of " Hydroa Puerorum," and Bazin, under the name at 
the head of this section, and others under the title of 
hydroa sestivale, have described a bullous disease that 
occurs in early childhood and upon exposed parts. It 
may occur on covered parts and later in life. It usually 
occurs in summer, and then seems to be due to the heat 
of the sun. It may occur in winter, and be due to 
the action of high winds. It is a symmetrical disease. 
There may be some malaise preceding the eruption which 
begins as erythematous spots on which the bullae form 
as such or as the result of the confluence of vesicles, and 
commonly both vesicles and bullae are present at the 
same time. The vesicles are prone to become depressed 
in the centre and resemble vaccine scars. Scarring is apt 
to result. Sometimes the disease does not go beyond the 
erythematous stage. Usually there is no itching, but pain 
or burning. A single attack lasts two or three weeks. 
The disease recurs from time to time, the relapses at 
times being so frequent as to render the disease almost 
continuous ; and tends to cease altogether as puberty 
is reached. The disease is related clinically to bullous 
erythema and to dermatitis herpetiformis, though it differs 
from them in leaving scars. 

Etiology and Pathology. Exposure to sun and 
wind seem to be the exciting causes, especially the former. 
It affects boys almost exclusively. Scholtz. 1 has found 
albumen in the urine during the attacks which disappears 
when the eruption does. He finds that the skin of the 
affected individuals is no more susceptible to the violet, 
ultra violet, and blue rays than that of others. He re- 
gards it as possible that some kind of systemic intoxi- 

1 Archiv Dermat. u. Syph. 1907, lxxxv., 95. 



348 DISEASES OF THE SICIX. 

cation is responsible for the peculiar reaction of the skin. 
Bowen has shown that it is inflammatory in character. 

The treatment is not very satisfactory. The exposed 
parts should be protected as much as possible from the 
action of the wind and sun by means of veils or a cala- 
mine lotion. If bullae form, they must be treated as in 
pemphigus. 

Hygroma Cysticum Colli Cogenitum. See Lymphan- 
gioma. 

Hyperesthesia. This is that condition of the skin in 
which pain is experienced on the slightest contact even 
of a current of air, in this differing from dermatalgia, in 
which the pain is spontaneous. When the sense of pain 
is exaggerated while the sense of touch is lessened, it is 
called Hyperalgesia. The hypersensitiveness may be for 
cold only, or for heat only, which is not so common. It 
is a neurotic disease, and is met with most commonly as a 
symptom of other diseases, such as non-tubercular leprosy, 
hydrophobia, and hysteria. Idiopathic cases are met with, 
though rarely. The hyperesthesia may be general or 
localized, unilateral or symmetrical. 

The treatment is in most cases that of the disease 
of which it is but a symptom, and belongs rather to the 
domain of the neurologist than to that of the derma- 
tologist. 

Hyperidrosis. Synonyms : Ephidrosis ; Idrosis ; Suda- 
toria ; Polyidrosis ; Excessive sweating. 

A functional disorder of the sweat glands characterized 
by an excessive flow of sweat. 

Symptoms. Hyperidrosis may be general or localized : 
unilateral or symmetrical ; in large or small amount. The 
cases of general sweating occur most often symptomati- 
cally in the course of general diseases, such as phthisis, 
malaria, and rheumatism, and do not concern us now. 
Some cases occur idiopathically. Such patients are 
usually fat. The hyperidrosis may be constant or at in- 
tervals, being excited by the slightest irritation of the 



HYPERIDROSIS. 349 

nervous system, or by muscular exertion. The outburst 
of the sweat is generally preceded by a prickling sensa- 
tion. It is often accompanied by prickly heat (lichen 
tropicus). 

We are called upon as dermatologists to treat localized 
sweating more often than the just-described variety, and 
such cases occur most commonly upon the palms and soles, 
in the axillae, about the genitals, and on the face and 
scalp. The excessive flow of sweat may be constant ; 
but it is usually paroxysmal, and often under the influ- 
ence of the emotions. It is usually more pronounced in 
warm than in cold weather. Fat people are more prone 
to it than are those who are thin : anaemic and delicate 
people rather than the robust. In some cases there may 
be a sense of tingling before the flow occurs. The af- 
fected part may be warm or cold ; if the first, it is apt 
to be somewhat hyperemia Occurring in places that 
are warm and covered, such as the feet, bromidrosis is a 
common accompaniment. The disease may last for years. 

Sweating palms usually feel cold and clammy. Some- 
times the amount of sweating is only enough to keep 
them more or less constantly moist ; sometimes it is so 
abundant that the sweat drops from the hands and 
fingers, or even fills up the hollow of the upturned palm 
and runs over the edge. It spoils gloves, and interferes 
with many forms of work. Sweating soles are soon fol- 
lowed by tender feet, the epidermis becoming sodden, 
macerated, and removed. It interferes with walking. 
The edge of the foot just about the soles appears as a 
white or gray line or seam of sodden epidermis with a 
pinkish seam above it. The sodden appearance is also 
well marked between the toes. Sweating in the axillae 
spoils the clothing, and is only rendered worse by the 
rubber dress-shields so commonly worn by women. Ec- 
zema accompanies it not infrequently. In its paroxysmal 
form it is frequently encountered in patients stripped for 
examination in public. Tins form has been aptly named 
by the French the " military sweat," as it is seen so often 



350 DISEASES OF THE SKIN. 

in examining recruits for the army. Sweating about the 
genitals is often accompanied by intertrigo, which may 
also occur on other parts subject to hyperidrosis where 
folds of skin are in contact. Sweating of the face is 
most commonly encountered upon the forehead, nose, 
and eyelids, beads of sweat standing out upon them or 
running off in little rivulets. It is here that hsemidrosis 
is most common. Upon the scalp it has been observed 
that its occurrence is frequently followed by loss of hair. 

Unilateral sweating is occasionally met with. It may 
affect half of the forehead, face, or whole body. Upon 
the forehead and face this form of sweating may occur as 
an accompaniment of migraine and limited to the painful 
region ; it is in paraplegia that one-half of the body alone 
is aifected. Kaposi x has reported one case of hyperi- 
drosis affecting only the upper half of the body. 

Etiology. The disease is probably due to a disturb- 
ance in the sphere of the sympathetic system. The 
slightest excitement, as that from taking a cup of tea, 
or some passing emotion may cause it in those predis- 
posed to it. It has followed lesions of the cerebro-spinal 
nerves. It occurs in all classes and conditions of men, 
and in all ages and both sexes. In some cases it is he- 
reditary. Ill health seems to be the cause in many cases; 
it may be anaemia ; chlorosis ; lithsemia ; hysteria ; or 
general debility. Flat foot is found in connection with 
some cases affecting the feet. In any case it is purely a 
functional disease of the sweat glands, they being struc- 
turally unchanged. 

The diagnosis is so evident that we neecPnot stop to 
differentiate it systematically. 

Treatment. The condition of the patient's health is 
to be carefully investigated, and tonics, mineral acids, 
nux vomica, or other medicine ordered according to the 
nature of the case. If there is no indication for this 
plan, or it does not succeed, recourse may be had to 
belladonna or atropia to the point of producing their full 
1 Arch. f. Dermat. u. Syph., 1899, xlix., 321. 



]£ Pulv. cretae co., 


3iij ; 


25 


Pulv. cinnam. co., 


5ij; 


15 


Sulph. pascip., 


3J; 


100 


Sig. A teaspoonful twice a day. 







HYPERWROSIS. 351 

physiological effect ; or pilocarpine -^ grain, three times 
a day ; or agaricin in doses of \ grain ; or ergot \ a 
drachm of the fluid extract three times a day. Crocker 
has found a full teaspoonful of precipitated sulphur in 
milk twice a day the best remedy. If it loosens the 
bowels too much, he prescribes it as follows : 



M. 



The local treatment of sweating hands and armpits in 
many cases is as unsatisfactory as the constitutional treat- 
ment. There have been many plans proposed. Local 
faradization is one agent. Very hot tvater may be 
sponged on for a few minutes ; belladonna ointment or 
liniment may be rubbed in ; or we may use some as- 
tringent application, as of subnitrate of bismuth, tannin, 
alum, sulphate of zinc, borax, and the like, in alcohol, 
ointment, or powder. As a rule, ointments cannot be 
used on the hands and face. The most reliable lotion is 
probably a saturated solution of boric acid, or a 3 per 
cent, solution of salicylic acid. Kaposi speaks highly of 
the good effect of bathing the parts with a 5 per cent, 
solution of naphtol in alcohol, and keeping them pow- 
dered with 1 part of naphtol to T l^ of starch. Piffard 
recommends freshly prepared silicic hydrate, 1 part, in 
cold cream, 9 parts. Sulphate of quinine, 5 per cent, 
in alcohol, may be tried. For sweating of the feet per- 
manganate of potash in 1 per cent, strength maybe used. 
Unna recommends ichthyol in 2 J per cent, ointment and 
the use of ichthyol soap. Formalin in 3 per cent, 
solution painted on three times a day has its advocates. 
P. Pichter 1 advises sprinkling tartaric acid between the 
toes and in the stockings for sweating of the feet ; and 
painting with a 10 per cent, solution of chromic acid 
every five days for sweating of the hands. Stelwagon 

i Allg. Med. Centr. Zeit., 1897, lxvi, 927. 



352 DISEASES OF THE SKIN. 

recommends a 10 to 20 per cent, tannic acid ointment, 
or diachylon ointment spread on cloths and applied 
snugly to the feet after washing them with soap and 
water. At the end of twelve hours the dressings are to 
be changed without washing, and so continued for ten to 
fourteen days. The skin usually exfoliates at the end of 
that time, and then the feet are to be washed and dressed 
with a dusting powder. For other methods see under 
Bromidrosis. The x-ray has proved useful in all forms 
of localized sweating, and may be used in obstinate cases. 
Pusey advises their use one to three times a week until 
the sweating is checked, care being taken to avoid pro- 
ducing erythema. If the trouble recurs this treatment 
is to be repeated. 

The prognosis is doubtful, many cases proving very 
rebellious to treatment. 

Hyperkeratosis Excentrica. See Porokeratosis. 

Hypertrichosis. Synonyms : Hirsuties ; Trichauxis ; 
Polytrichia ; Dasyma ; Trichosis hirsuties ; (Fr.) Poils 
accidentels ; Superfluous hair. 

Symptoms. Hypertrichosis is a growth of hair that is 
either abnormal in amount or occurs in places where, nor- 
mally, only lanugo hairs are present. It may be general 
or partial, congenital or acquired. The general form is 
also congenital, but it is never universal, as no hair grows 
upon the palms and soles, the backs of the last phalanges 
of the fingers and toes, the inside of the labia majora, the 
prepuce, and glans penis. Subjects of this malady are 
usually born covered more or less thickly with hair, which 
may be light or dark in color. This continues growing 
longer, coarser, and darker till it reaches its full develop- 
ment. As a rule, the long hair covering the body is fine, 
resembling more the hair of the head than that of the 
beard, as is also the case with the hair on the face of these 
people. With this excessive growth of hair there is 
usually combined a deficiency of teeth, especially marked 
in the upper jaw. Subjects of this malady are called 



HYPERTRICHOSIS. 353 

homines pilosi, and are met with in all quarters of the 
world. 

Of partial congenital hypertrichosis we have an immense 
number of examples. This condition is apt to be of the 
nature of nsevus. The distinction between a localized 
hypertrichosis and a nsevus is made mostly upon the color 
of the underlying skin. In the former case the skin is 
perfectly normal, while in the latter it is pigmented and 
may be otherwise altered. These localized and partial 
cases of hypertrichosis are most frequently met with in 
the sacral or lumbar region, and not infrequently are asso- 
ciated with spina bifida. 

Partial acquired hypertrichosis is more common than is 
the congenital variety, and takes the form either of an ex- 
cessive growth of hair in regions where it is usually found, 
or of the development of hair in regions usually hairless or 
provided only with downy or lanugo hair, or of the devel- 
opment of pubertal hair at an early age. 

The following cases are instances of excessive growth 
and precocious development. Chowne * speaks of a boy, 
eight years of age, who had the whiskers of a man. Beigel 2 
has seen a six-year-old girl with pudenda like a twenty- 
year-old woman, both in shape and hair. A case of 
excessive growth was met with by Leonard 3 in a man 
whose beard measured seven feet six and a half inches in 
length. Other instances of excessive length of beard 
are found in medical literature. 4 Many men have an 
excess of hair upon the chest and shoulders. Hair is 
generally better developed upon the forearm than upon 
the upper arm, and upon the legs than upon the thighs. 
As men grow old they are apt to have long hairs grow 
from the nostrils and the ears. These are instances of 
the growth of strong hair where normally only lanugo 
hairs are present. 

i Lancet. 1852, i., 421. 

2 Virchow's Archiv, 1868, xliv., 418. 

3 The Hair ; its Diseases and Treatment. Detroit, 1881. 

4 Jackson ; Diseases of the Hair and Scalp. New York, 1887, 

23 



354 



DISEASES OF THE SKIN. 



The growth of the beard in women is the form of hyper- 
trichosis which concerns us most, as it is the deformity 
which we will be called upon to cure. As women grow 
old, especially after they have passed through the meno- 
pause, a slight mustache or a few straggling dark hairs on 





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Hirsuties. 1 



other parts of the face often appear. These growths sel- 
dom annoy them much, as they are accepted as evidences 
of advancing years. The case is very different when a 
young woman is afflicted with a beard, and most of the 
patients who apply for relief from their facial hair are 
between twenty and thirty-five years old. In them the 

1 By the courtesy of Dr. S. Dana Hubbard. 



HYPERTRICHOSIS. 355 

hair generally begins to grow so as to be noticeable at 
about the eighteenth year of age. To get rid of the 
trouble the tweezers are first resorted to ; then depilato- 
ries are tried; sometimes burning is attempted, and as a 
final refuge a razor is used. All the time the hair grows 
coarser and more abundant. Some of these women shun 
company, keep themselves shut up all day, their health 
deteriorates, and, constantly brooding over their misfor- 
tune, they are prone to become hypochondriacal and mel- 
ancholic. The amount of hair present in these cases 
varies. Perhaps the commonest growth is the mustache 
alone. In most of my cases the hair has grown thickest and 
coarsest under the chin and upon the front of the throat. 
It is rare, even in the best developed cases, to have much 
hair under the lower lip. Sometimes the growth is as 
complete, as heavy, and as coarse as is met with in men. 
The skin in many cases is coarse, muddy, greasy, and 
studded with acne. 

From time to time cases of transitory hypertrichosis 
have been reported. This has been noticed during the 
treatment of a fractured limb, the hair being much more 
prominent upon the part that has been kept quiet and 
warm. In some of these cases the increase is probably 
more apparent than real, the hair not having been rubbed 
off by friction. Likewise, after injury to nerves the hair 
sometimes becomes hypertrophied, only to fall out after 
recovery. Continued irritation of a part, as by blisters, 
may stimulate hair-growth which may or may not be 
transitory. The most interesting of this group of cases 
is that comprising those of hirsuties occurring during 
pregnancy and disappearing after some months. Wilson 
reported a case of delayed appearance of menstruation in 
which hair grew upon the face. After the menstrual 
function was established the hair ceased to grow and 
gradually disappeared. 

Etiology. The cause of hypertrichosis is very ob- 
scure in some of its forms, while in other varieties we 
can more readily discover it. In general congenital 



356 DISEASES OF THE SKIN. 

hirsuties heredity plays an important part. But heredi- 
tary tendencies will not explain the first appearance of 
these congenital cases. Virchow endeavored to account 
for them upon the theory of nervous influence, founded 
upon the fact that in the Kostroma people — a markedly 
hairy father and son — the lack of development of the 
teeth and jaws was in the same zone as the over-develop- 
ment of the hair on the forehead, nose, cheek, and ears ; 
these regions all being supplied by branches of the trige- 
minus or fifth cranial nervp. Unna's theory of congeni- 
tal hypertrichosis is that it is due to a persistence of the 
foetal or primitive hair ; the change of type between the 
primitive and permanent hair not taking place. 

The cause of acquired hirsuties is, in some cases, not 
far to seek. Heat and moisture will apparently increase 
the growth of hair, just as they favor the growth of 
vegetable life. Thus the hair has grown luxuriantly 
under the stimulation of poultices, and on the limbs when 
confined in a fracture-box. To these factors must be 
added an increase of the flow of blood to the part. In- 
crease of the flow of blood will stimulate hair-growth 
independently of heat and moisture. At least Prentiss's 
case of hair growing more luxuriantly and coarser under 
the use of pilocarpine, which causes hyperemia of the 
skin, would seem to indicate this. Hypertrichosis fol- 
lowing injury to nerves is probably dependent upon vaso- 
motor disturbances. The growth of hair upon exposed 
parts, as upon the arms and chest of laboring-men, sailors, 
and the like, is due to the local irritation of the sun and 
wind. 

Now we come to the more obscure cause of facial hirsu- 
ties in women. To account for this, numerous hypotheses 
have been formed. Probably the one most generally 
accepted is that it is in some way connected with de- 
rangement of the uterus and appendages. Because in some 
bearded women there has been some evident derangement 
of the sexual organs, it has been affirmed that some similar 
derangement is present in all. This is on a par with the 



HYPERTRICHOSIS. 357 

too loosely accepted idea that the too free use of alcohol 
is the only cause of rosacea. In the cases I have met 
with, the majority were as free from uterine trouble as the 
rest of their sex. While it is true that some of these 
women are of masculine build, aud have a masculine voice, 
most of them do not exhibit these characteristics. In 
some cases, however, there does seem to be some relation 
between the reproductive organs and the growth of the 
beard. Heredity is well marked in the majority of cases. 
It is improbable that attempts at destroying the fine hair 
cause the development of the coarse hair. It is more 
likely that they only strengthen its growth. Women are 
prone to trace the appearance of hair on the face to the 
use of vaseline, cold cream, and the like. There is no 
scientific foundation for this. 

An interesting study of the relation between hirsuties 
in women and insanity was made by Hamilton. 1 He re- 
gards hair-growth on the face in women as the inevitable 
result of the over-active and continuous exercise of the 
uterine and ovarian functions. He believes it to be of 
neuropathic origin, connected with disorders of the fifth 
cranial nerve ; and that when it occurs upon the face of 
an insane person it is indicative of an unfavorable form 
of insanity, especially if the subject has not reached mid- 
dle life. E. Dupre and Duflos 2 found among 1 000 sane 
women 230 with fine hair on the face, 40 with a medium 
growth, and 10 with a heavy growth. Among 1000 in- 
sane women they found 441 with a slight or medium 
growth of hair and 56 with a heavy growth. They also 
found evidences of neuropathic tendencies and mental 
derangements in the antecedents of many non-insane 
women with hirsuties. 

We may sum up the evidence on the etiology of facial 
hirsuties in this way : While at times there appears to be 
a relation between the uterine, or, more properly, the 
menstrual function, and the growth of hair on the face, 

i Med. Rec, 1881, xix., 281. 

2 Annale derm, et syph., 1902, 111-806. 



358 DISEASES OF THE SKIN. 

shown by a decrease or deficiency of the first, and an in- 
crease of the second, still in the majority of cases no such 
relation is discoverable, and it must be viewed as a de- 
formity, or a freak of Nature, or as a matter of inheri- 
tance. 

Treatment. For general hypertrichosis we can prac- 
tically do nothing. This, not because we cannot destroy 
hair so that it will not grow again, but because of the 
great amount of time it would take to destroy it. 

The only form of hirsuties which urgently calls for re- 
lief is that occurring upon the face of women. In 1875 
Dr. Michel, of St. Louis, devised the method of remov- 
ing the hairs in trichiasis by means of electrolysis, which 
was taken up by Dr. Hardaway, of the same city, for the 
removal of superfluous hair. The question is often asked : 
" Is the removal, by this method, permanent ?" This 
question may be answered, " It is, without a shadow ot 
a doubt/ ' The object being to destroy the papilla, and 
that being very small and often placed at an unexpected 
angle to the surface of the skin, it is not possible always 
to accomplish this at the first attempt ; but with patience 
and the necessary skill it will finally be permanently de- 
stroyed. At times, after the dark, coarse hairs have been 
removed, there will be found a number of finer and lighter 
hairs. This appearance is due partly to the uncovering 
of these hairs, and partly, it may be, to lanugo hairs be- 
coming stronger under the stimulation of the operation. 
In most cases, with proper care and the use of a fine 
needle, the amount of scarring will be very slight, amount- 
ing to nothing more than fine punctate cicatricial spots. 
In some peculiarly irritable skins it is very difficult to 
prevent the formation of plainly visible scars. The upper 
lip is also prone to scarring. If the proper conditions 
are not observed, the operator must expect to produce a 
good deal of disfigurement. 

The amount of pain experienced by the patient will 
vary greatly. Certain parts of the face are far more 
sensitive than others. On the whole, the pain does not 



HYPERTRICHOSIS. 359 

amount to much. After a time the skin seems to become 
tolerant of the action of the current and the patient ' no 
longer complains. Hyperpigmentation maybe produced 
by the operation. This is a very rare complication, and 
is mentioned only by way of warning. 

The instruments needed- for the operation are a good 
twenty-cell zinc-carbon (galvanic) battery, a sponge elec- 
trode, a proper needle-holder, a fine needle, a pair of epi- 
lating-forceps, and, if the operator's eyes are not good, a 
lens of low power. Any sponge electrode will answer. 
There are various patterns of needle holders, any one of 
which may be used. It should be long enough to be held 
with ease, and not too long to be readily manipulated. 
The most essential instrument is the needle. Hardaway 
recommends a needle made of iridium and platinum. He 
claims that it will follow the direction of the hair follicle, 
and more surely hit the papilla than with a steel needle. 
I have had most satisfactory results with a jeweler's in- 
strument called a "steel broach." These come in many 
grades ; those known as Nos. 5 and 7 are serviceable ones. 
A lens is generally not needed. Dr. PifFard has invented 
a needle-holder with lens-attachment, which he has found 
useful. If one's eyesight is not good, he had best wear 
spectacles furnished with large magnifying lenses. A 
galvanometer is not essential, but very desirable. 

A good light is necessary for the operation, and a 
cloudy day is a bad one for working. An operating-, 
reclining-, or dentist's chair is a comfort, and the patient 
should be so placed that the part to be operated on is on 
a level with the operator's eye. The operation is done 
in the following manner : The patient, being in position, 
is to be given the sponge electrode attached to the posi- 
tive pole of the battery, and told to hold it in one hand. 
The hair to be extracted is then seized with the forceps, 
and put slightly on the stretch in the direction in ivhich 
it naturally grotvs. The needle, attached to the negative 
pole, is then inserted parallel with the hair and into the 
follicle. One soon learns to know whether the follicle 



360 DISEASES OF THE SKIN. 

is entered or not by the sense of touch. When the 
follicle is entered the needle glides along smoothly ; 
when it is not entered a sense of resistance is communi- 
cated to the fingers as the skin is punctured. The depth 
to which the needle is to be thrust will vary with the 
case. Roughly speaking, it is from y 1 ^ to T 3 g- of an 
inch. The needle being inserted, the patient is told to 
place the palm of the disengaged hand over the sponge 
electrode. In a few moments there will be frothing about 
the needle, and in from half a minute to a minute or 
more the hair will come away upon the very slightest 
traction. The hand is to be removed from the sponge 
before the needle is withdrawn from the follicle. The 
hair must not be pulled on with any force, for the ease 
with which it leaves the follicle is evidence of the com- 
pleteness of the operation. The hairs must not be ex- 
tracted in close proximity, because the inflammatory ac- 
tion thus set up will lead to more or less deep ulceration 
and subsequent prominent scars. It is best to extract 
only the coarser hair, and to leave the lanugo hairs alone. 
The strength of the current to be used will depend upon 
the quality of the patient's skin and the recentness of the 
filling of the battery. Six cells are the fewest I have 
used, and fifteen the greatest number — more exactly, a 
current-strength of 1 to 2 milliamperes. 

Immediately after operating the part worked on should 
be washed with peroxide of hydrogen or any antiseptic 
solution. The patient should be directed to bathe the 
face in hot water and to anoint it with cold cream several 
times during the day following the operation. 

T. Bloebaum 1 advocates the use of galvano-caustic 
needles as superior to electrolysis for the destruction of 
hair. A platino-iridium needle is used by him, which 
is thrust while glowing 2 or 3 times into the follicle, and 
thus he destroys one hundred hairs in fifteen minutes. 
He claims for his method not only greater celerity, but 
also less scarring and pain. The micro-brenner of Unna 
1 Deutsche med. Zeit., 1897, xviii, 609. 



HYPONOMODERMA. 361 

has its advocates. Ivromayer 1 recommends the use of 
specially constructed cylindrical knives from 0.1 to 2 
mm. diameter, which are driven into the skin to the depth 
of 1J mm., and at once withdrawn. The hair comes 
away with the knife, or can be readily plucked out. He 
claims that this method does not leave scars. 

Of late, the x-rays have been used to destroy hair, and 
apparently successfully. The operation has to be often 
repeated, sometimes as many as 40 to 100 times. Short 
and mild exposures should be given, so as not to cause 
more than a passing erythema. They should be stopped 
as soon as the hair falls, or an erythema occurs. After 
waiting six weeks a second, shorter, course of exposures 
should be made. There is always danger of dreadful 
scarring, and the production of lasting pigmentation and 
wrinkling of the skin with many telangiectases from 
their use, but improvement in technique is constantly 
lessening these dangers. In from J to J of the cases 
a successful result has been had. It is to be recom- 
mended only in very bad cases, where the patient prefers 
the wrinkled skin to the hair. 

The hair may be temporarily removed by pulling or 
shaving, or the use of depilatories. Of the latter, sul- 
phide of barium 2 drachms, oxide of zinc and starch 
each 3 drachms may be used. The powder is to be mixed 
with water to the consistence of a paste, which is spread 
on the part for ten to fifteen minutes or until a certain 
amount of warmth is felt. It is then to be washed off 
and a soothing ointment applied. Any of these proced- 
ures makes the hair grow coarser. Peroxide of hydrogen 
may be advised to bleach dark hair and thus render it 
less conspicuous. 

Hypohydrosis. See Anidrosis. 

Hyponomoderma, or creeping eruption is a disease of the 
skin due to its invasion by the larva migrans of gastro- 
philus. In this country it is very rare, but in Russia and 

1 Deutch. med. Woch., 1905, xxxi, 179. 



362 



DISEASES OF THE SKIN. 



Arabia it is said to be common. It is recognized as an 
irregular, tortuous, narrow, raised red line from one-sixth 
to one-eighth of an inch wide. It will be noted that the 
line extends over the surface at the rate of about one inch 
a day. The beginning of the track fades after a few 

Fig. 47. 




Hyponomoderma. (After Van Haelingen) 

days. There is no definite course of the disease. Crocker 
records a case which had continued extending for two and 
a quarter years. There may be some pruritus and the 
skin may be scratched. Any part of the body may be 
affected. 

The larva is scarcely 1 mm. long, broadest in the 
middle, and bifurcated posteriorly. It is marked by 



ICHTHYOSIS. 363 

numerous black plates, aucl has hook-like prickles ar- 
ranged in nine rings about the body. About the mouth 
are a number of large and small prickles placed thickly 
in rows, from which protrude two small mouth-hooks. 
They live normally in the horse's stomach. It is prob- 
ably the eggs that are deposited on the skin of humans. 
(Boas. 1 ) 

The treatment is by excision of the dark end of the 
track. Stelwagon cured one case by cataphoresis with a 
solution of 2 grains to the ounce of bichloride of mer- 
cury to an inch and a half area about the advancing end, 
and nitric acid to the suspected site of the parasite. 

Hysterical Gangrene: See Dermatitis gangrenosa. 
Hystricismus. See Ichthyosis. 

Ichthyosis. Synonyms : Xeroderma ; Xeroderma ich- 
thyoides ; Ichthyosis vera, seu congenita ; Sauriasis ; 
(Fr.) Ichthyose ; (Ger. ) Fischschuppenausschlag ; Fish- 
skin disease. 

Ichthyosis is a congenital, general or partial, chronic 
disease of the skin, characterized by dryness, harshness, 
and scaling of the skin, and sometimes by the develop- 
ment of warty-looking growths. 

Symptoms. Though the disease is congenital, it usually 
does not show itself until after the second month, and 
sometimes not until the second year. There are three 
varieties of the disease, namely, xeroderma, ichthyosis 
simplex, and ichthyosis congenita. 

Xeroderma is the mildest grade of the disease. The 
skin is dry, harsh, slightly scaly, grayish or dirty-look- 
ing, and its natural lines are more pronounced than usual. 
Upon the extensor surfaces of the limbs it is particularly 
marked, and here too it is accompanied by keratosis pilaris. 
It is most annoying to young women who want to wear 
short-sleeved dresses. It is doubtless far more common 
than statistics show, as it very often is slight in amount. 

Ichthyosis simplex. This is a more severe grade of the 

i Mutshft f. prt. Dermat., 1907, xliv„ 505. 



364 



DISEASES OF THE SKIN. 



disease in which the skin is dry, harsh, and scaly, and 
divided off into small diamond - shaped or polygonal 
figures (Fig. 48). While the whole cutaneous surface 
may be involved, the disease is usually most pronounced 
upon the extensor surfaces of the legs and arms. The 
face, scalp, palms, and soles are often spared. The skin 

Fig. 48. 




Ichthyosis 

about the extensor surfaces of the elbows and knees is 
generally thrown into well-marked folds, while the flexor 
surfaces of the same joints are unaffected, the skin in 
these situations being soft and natural. While upon the 
extremities the disease is well developed, upon the trunk 
it may assume more of the xerodermatous form. When 
the face and scalp are affected they are simply very scaly, 



ICHTHYOSIS. 365 

while on the palms and soles we have accentuation of the 
normal lines. In a typical case the skin, especially of the 
extremities, will be grayish, greenish, or blackish green 
in color, dry, and the little polygonal plates will be at- 
tached at their centres and turned up slightly at their 
edges, so that they appear depressed in the centres. The 
amount of loose scaling is sometimes abundant, but 
usually moderate in amount. The hair, if the scalp is 
involved, is dry. The nails are often pitted. Ectropion 
may result in those rare cases in which the disease affects 
the face severely. Itching is often complained of, and 
eczema may complicate matters. There are a marked 
absence of perspiration and lessened sebaceous secretion ; 
and the patients are sensitive to cold. The disease is 
usually worse in cold weather. 

Ichthyosis hystrix is a very rare form of ichthyosis, 
and occurs in the form of patches or warty, dark-green, 
papillary projections markedly raised above the skin, or of 
small papillary growths with horny caps. The skin feels 
rough and harsh. It may cover wide areas of the body, 
but does not involve the whole surface. The same name 
has been applied to an entirely different disease that is 
described under Papilloma lineare, to which the reader 
is referred. 

Ichthyosis congenita is the most rare form of the dis- 
ease. It is also called Keratoma follicularis, Keratosis 
diffusa, seu epidermica, seu intra-uterina, and the " Har- 
lequin foetus." It is considered by some to be a general 
seborrhoea. It is present at birth, the skin being covered 
with fatty epidermic plates cracked in all directions and 
arranged transversely to the axis of the body. The fis- 
sures may extend into the corium. The eyes are held 
partly open, or there may be ectropion ; the lips cannot 
be moved ; and the feet are contracted and deformed. 
The color is yellowish white or grayish. The scrotum 
and penis may not be involved. The infants are either 
born dead or survive birth but a short time, though 



366 DISEASES OF THE SKIN. 

S. Sherwell has reported one case that was living at five 
months of age. 

There are also cases of ichthyosis intra-uterina in which, 
after the removal of the vernix caseosa, the skin looks 
red, glazed, and dry, and soon assumes the characteristics 
of ichthyosis simplex. 

With the exception of ichthyosis congenita, the dis- 
ease does not show itself until some months after birth, 
but by the second year it has made its appearance. 
As a rule, it increases in severity as the patient grows 
older, until adult age, when it usually remains stationary 
or perhaps improves a little. It is a chronic disease and 
shows no tendency to get well. It does not seem to 
affect the patient's health, and it should be regarded 
rather as a deformity than a disease. Occasionally 
mental weakness and other congenital defects have been 
noticed. 

Etiology. We know of no cause for the disease be- 
yond heredity, which may be direct, skip a generation, or 
be through a lateral branch. Many cases occur without 
manifest heredity. It has been ascribed to consanguinity 
of the parents. It attacks both sexes about equally. It 
shows a tendency to occur only in one sex in certain 
families, while in other families both sexes are equally 
affected. It is a congenital defect in the development of 
the skin with a disturbance of the functions of the 
perspiratory and sebaceous glands. There are said to be 
cases of the disease that are not hereditary, but due to 
well-marked nerve disturbances, greatly reduced nutrition, 
and the drinking of ava, a fermented liquor in use in the 
Hawaiian Islands. 

Pathology. The epidermis undergoes a peculiar cor- 
nification. Horny cells are formed directly from the rete 
without the intervention of a granular layer. The horny 
cells are homogeneous and apparently without nuclei. 
Exfoliation is slowed and the thickness of the epidermis 
is due to its longer retention. The sweat and sebaceous 
glands are constantly atrophied, or the latter may be 



ICHTHYOSIS. 367 

entirely wanting. The panniculus is absent, the elastic 
tissue unaltered, and the erectores pilorum hypertrophied. 

Diagnosis. The disease is so unique that if its char- 
acteristics are remembered there can be no difficulty in 
diagnosis. There is no other disease commencing in 
infancy that at all corresponds to ichthyosis simplex. 
Xeroderma may resemble a mild grade of squamous 
eczema, but has not its history. Sometimes we meet 
with a dry skin that is not ichthyosis, but is only a 
passing state and has not existed from infancy. Ichthy- 
osis congenita differs from seborrhoea in not being remov- 
able by soaking in oil and by proving fatal. 

Treatment. The treatment is largely palliative. 
The free use of Russian baths or of prolonged warm baths, 
simple or with soda, and washing with soap, followed by 
inunctions of vaseline, lanolin, or oil, such as cocoa-butter, 
will keep the skin supple. Kaposi recommends a 5 
per cent, naphtol ointment, or a 2 per cent, solution in 
spiritus sapo, viridis, or cod-liver oil, in conjunction with 
naphtol soap. Andeer 1 recommends a 3 to 20 per cent, 
ointment of resorcin well rubbed in, and covered with a 
bandage, and claims a cure in eight days. Sulphur oint- 
ment also has been recommended. The daily application 
of a lotion composed of J an ounce to 1 ounce of glycerin 
in a pint of rose-water or of lime-water is one of the 
simplest and best methods of treatment. Whatever is 
used must be persisted in. 

M. Bockhart 2 reports one apparent cure by giving a 
daily morning bath with soap and water, followed by an 
inunction of a 5 per cent, sulphur ointment. The oint- 
ment was used also at noon and at night. Internally, cod- 
liver oil was given. Twice a year for six weeks salt baths 
were substituted for the soap-and-water baths. After 
three years of continuous treatment a pause was had and 
there was no return for three months. After nine years' 

1 Monatshefte f. prakt. Dermat., 1884, iii., 365. 

2 Ibid., 1901, xxxiii., 616. 



368 DISEASES OF THE SKIN. 

treatment, with pauses in between, the patient was well, 
and remained so up to the time of writing, after six years. 

Besnier recommends, as adjuvants to the local treat- 
ment, regular gymnastic exercise and the internal admin- 
istration of cod-liver oil. Thyroid extract has been used 
with benefit in some cases. It should never be used 
unless the patient can be watched by the physician, as it is 
a dangerous remedy. The administration of jaborandi 
by the mouth or pilocarpine hypodeimically will soften 
the skin, but in a deformity of the skin that cannot be 
removed its use is inadvisable. 

Axmann 1 reports a cure by the use of the Schott 
Uviol lamp. After nine sittings of ten minutes each the 
skin was smooth. After a pause of four weeks, nine 
more sittings were given. After thirty-five sittings with 
from eight to fourteen day pauses, the disease was cured. 

D. H. Stewart 2 affected a permanent cure of one case by 
irrigation of the colon with 5 gallons of water at a tem- 
perature of 120° Fahr., containing 4 tablespoon sful of 
table salt to the gallon. This was given one day, and 
on the next a pill of calomel and hyoseyamus was admin- 
istered. This alternating treatment was continued for 
four weeks, when the skin became smooth and has so 
continued for more than two years. 

Prognosis. The prognosis is good as to life, bad as to 
cure. Thus far it has proved practically incurable. All 
one can hope to accomplish is to render the patient com- 
fortable and fit to mingle with his kind by repeated 
courses of treatment. Ichthyosis congenita is fatal in a 
few days, if the child is not born dead, as is usually the 
case. 

Ichthyosis Follicularis. See Keratosis follicularis. 
Ichthyosis Sebacea. See Seborrhoea sicca. 
Idrosis. See Hyperidrosis. 
Ignis Sacer. See Zoster. 

1 Dermat. Zeitschrift, 1907, xiv., 109. 

2 Jour. Cutan. Dis. 1905, xxiii., 52. 



IMPETIGO OF BOCKHAEDT. 369 

Impetigo Simplex. Our own writers largely follow 
Duhring in their description of this disease, and as soon 
as they vary from his description, it seems to me that, 
instead of simple impetigo, they describe the contagious 
form. I have never recognized a case, and shall here 
follow Duhring. The appearance of the disease may or 
may not be preceded by loss of appetite, constipation, 
or malaise. The eruption consists of one to a dozen 
or more pustules that are pustules from the beginning. 
They are split-pea to finger-nail in size, rounded, and 
raised above the surface of the skin. They have thick 
walls, a more or less marked areola, little surrounding in- 
filtration, and no central depression. Their color is yel- 
lowish or whitish. They manifest no disposition to rupt- 
ure, are discrete and disseminated, and do not incline to 
coalesce. While they may occur anywhere, they are 
seated by preference on the face, hands, feet, and lower 
extremities. Itching and burning are absent, as a rule. 
The course of the disease is acute, its duration being 
several weeks. The pustules gradually undergo absorp- 
tion and dry into a crust, or they may be ruptured by 
external injury. The crust when it falls leaves a red- 
dish base without pigmentation or scar. The disease is 
not contagious, and occurs mostly in children. 

Such is the disease as described by Duhring. It will 
be seen by reading the section on impetigo contagiosa 
that it bears a strong resemblance to that disease. He 
differentiates it from impetigo contagiosa on account of its 
being pustular and not vesico-pustular from the start, 
its deeper seat, and its being more raised and not umbili- 
cated. 

Impetigo of Bockhardt. The best description of this 
form of impetigo is by Sabouraud. l He describes it as 
occurring primarily on hairy regions, usually the scalp, 
as an eruption of pustules pierced by hairs. They are 
confluent or disseminated. They are yellowish green, 

1 Ann. de derm, et de syph., 1900, i., 62 and 427. 
24 



870 DISEASES OF THE SKIN. 

rounded, umbilicated or accumulated, and vary from millet 
to pea size. There is an areola about the young pustules 
which diminishes with their age. They are not readily 
broken. They reach full development in three to five 
days, the crust falling in a week. A folliculitis is often 
left, or a furuncle or abscess follows. There is some- 
times a dermatitis of the scalp of severe grade, and the 
glands of the neck are often swollen. Successive crops 
of pustules are frequent, thus prolonging the course of 
the disease. The disease may spread from the scalp to 
the face, neck, back, thighs, and buttocks. It is due to 
infection with the staphylococcus aureus, and is regarded 
by Sabouraud as being distinct from impetigo contagiosa, 
though often complicated by it. His view is not accepted 
by all. Crocker regards it as simply a form of contagi- 
ous impetigo. 

Impetigo Contagiosa. Synonyms : Porrigo contagiosa ; 
Impetigo parasitica ; Pemphigus acutus contagiosus adul- 
torum. 

An acute, inflammatory, contagious disease, occurring 
especially on the face, hands, and exposed parts, and char- 
acterized by the appearance of vesico-pustules and bullae. 

Symptoms. By Tilbury Fox, who first described the 
disease, and others who followed him, its onset is said to 
be marked by slight febrile disturbances. These are very 
slight, and I have not satisfied myself as to their occur- 
rence in the many cases that I have seen, except incident- 
ally as part of some digestive disorder that may be present. 
The eruption consists of flat vesico-pustules that come out 
in crops. They are of various sizes, from a pea to a finger- 
nail. They are at first surrounded in well-marked cases 
with a red halo, which soon fades. They tend to in- 
crease slowly in size, and sometimes assume an annular 
shape. They are not fully distended, but flaccid, and 
not infrequently upon the hands they bear a strong re- 
semblance to a burn of the second degree. If the covers 
of the vesicles or small bulla? are not disturbed, their con- 



IMPETIGO CONTAGIOSA. 



371 



tents in a few days will dry up, and the vesico-pustule 
will change into a straw-yellow granular crust, which is 
placed superficially upon the skin with its edge some- 
what detached, and, it may be, turned up — in fact, it 
looks " stuck on." When the crust is removed or falls 



Fig. 49. 




Impetigo contagiosa. 1 

of itself, there is exposed an erythematous spot, which in 
a short time will disappear and leave no trace of its ex- 
istence. If the vesicles are torn by scratching, or if by 
any other means their covers are removed, we shall find 
very superficial losses of substance — a moist surface 
covered with a slight purulent secretion, or crusted lesions. 
Even this disappears and leaves no trace, passing through 

i G. H. Fox. The Skin Diseases of Children. New York, 1897, 



372 DISEASES OF THE SKIN. 

the erythematous stage in its course to recovery. Such 
are the appearances presented in the majority of cases. 
In adults the lesions sometimes assume a circinate form, 
but the ordinary impetigo lesions are also present. 

Besides this usual and typical form we meet with 
another and rarer variety, in which, instead of vesico- 
pustules, there are large bullae. These may be several 
inches in their long diameter, are of irregular oval shape, 
not fully distended with fluid, and sometimes show a 
slight depression in their centres. Their contents are at 
first serous, but soon become sero-purulent. They seem 
to be longer preserved than the vesicles, but otherwise 
run the same course. At first they have a slight zone of 
redness about them, but this soon disappears. They 
either are formed by two or morevesico-pustules running 
together, or spring up of themselves. They may attain 
their full size at once, or enlarge slowly. Rarely do 
they exist alone ; generally the typical vesico-pustules 
will be found in their neighborhood or elsewhere on the 
body. It is the bullous form that is liable to be mis- 
taken for pemphigus, and has been called contagious pem- 
phigus. 

Impetigo contagiosa is located principally upon the face, 
most often on the chin, and on the hands ; it may also 
occur upon the scalp, legs, and trunk, especially in infants. 
According to my experience, the bullous form is most 
often seen upon the trunk. The lesions of both varieties 
are discrete ; exceptionally two or more may run together. 
They are superficial, and rarely very numerous. The 
bullous lesions are generally widely separated from one 
another. The disease does not run any definite course, 
and may last weeks or months ; a slight amount of itch- 
ing is sometimes present. 

Etiology. It is, as its name indicates, very conta- 
gious, and often occurs in epidemics. When one case is 
met with in dispensary service, several more may be 
expected in children of the same family or neighborhood. 
It is readily inoculable both on the subject of the disease 



IMPETIGO CONTAGIOSA. 373 

and on others. Not infrequently we see a mother or 
other attendant of a child with the characteristic lesions 
of impetigo contagiosa upon the arms, derived from car- 
rying the child suffering with the same disorder. The 
contagious element is a microorganism. We know that 
all pus is under certain circumstances inoculable, and 
hence it has been maintained that there is no such disease, 
properly speaking, as contagious impetigo. But when we 
succeed in inoculating from an ordinary pustule, we pro- 
duce an ordinary pustule, not the characteristic vesico- 
pustule of impetigo contagiosa. It has been stated by 
some authorities that the disease is due to an inflamma- 
tion set up by lice on the head of the particular case or 
can be traced back to some other case of pediculosis. In 
some cases phtheiriasis capitis may be present, because 
both diseases occur with special frequence in children of 
the poor. In my own experience, in most cases no such 
relationship can be traced. Cases of contagious impetigo 
sometimes follow vaccination, and thus has been sug- 
gested the possible connection between impetigo and vac- 
cinia. In is more frequent in the warm months than in 
the cold. Children furnish the vast majority of the cases. 

Pathology. The pustule is roofed in by the horny 
layer, and its floor is the rete. The upper part of the 
corium displays a mild acute inflammatory reaction, with 
the usual features. By most observers the disease is 
thought to be due to staphylococcus aureus. Kauffmann * 
thinks he has found a staphylococcus that differs from the 
ordinary staphylococcus pyogenes in its cultures, in its 
less resistance to destructive agencies, in its inoculations 
producing vesicles and not pustules, and in beiug less 
virulent. Sabouraud 2 and others believe it to be due to 
streptococcic infection ; while still others have found now 
the one and now the other form of coccus in the disease. 
It is evident we need still more light on this subject. 

Diagnosis. Impetigo contagiosa is diagnosed by the 

1 Dermat. Zeitschrift, 1899, vi., 792. 

2 Ann. de derm, et de syph., 1900, i., 62. 



374 DISEASES OF THE SKIM 

presence of discrete, partially distended vesico-pustules, 
which are located npon the exposed parts — head, face, 
and hands — in most cases ; these are sometimes grouped, 
run an acute course, and dry up into straw-yellow "stuck- 
on " crusts. It is sometimes preceded by slight consti- 
tutional disturbances, and accompanied by a slight amount 
of itching. It must be differentiated from simple impe- 
tigo, pustular ezcema, varicella, scabies, pemphigus, and 
possibly ecthyma. 

The lesions of simple impetigo are pustules from the 
start, while those of impetigo contagiosa are first vesicles 
and then vesico-pustules. The pustules of impetigo are 
prominently raised, and run no definite coarse. The 
vesico-pustules of impetigo contagiosa are flattened, and 
run a rather definite course. The crusts of impetigo are 
generally greenish, while those of the contagious form are 
yellowish. Impetigo is not so readily inoculable as is 
impetigo contagiosa, and is much more widely dissemi- 
nated, as a rule. Simple impetigo is a deeper process 
than the contagious form. 

Pustular eczema is itchy; its pustules tend to break 
down quickly, run together, and form large patches, which 
soon become covered with a greenish or blackish crust. 
These phenomena are entirely foreign to impetigo conta- 
giosa. Eczema does not present vesico-pustules nor 
bullae, as a rule. Varicella is an acute contagious disease, 
with constitutional symptoms in most cases. Its vesicles 
are smaller than those of impetigo contagiosa, and they 
run a definite course peculiar to themselves. They are 
widely distributed over the whole surface, usually appear 
first on the trunk, sometimes occur on the fauces, and not 
infrequently leave pitted scars. Contagious impetigo is 
in most cases limited to the exposed parts, it never occurs 
upon the fauces, and its lesions leave no trace. The 
crusts of varicella are small, while those of contagious 
impetigo are large. 

The diagnosis from scabies offers little difficulty. In 
fact, the location of both diseases upon the back of the 



IMPETIGO CONTAGIOSA. 375 

hands is their strongest point of resemblance. When we 
bear in mind that scabies is very itchy, that it occurs 
usually as a copious eruption upon the hands, wrists, and 
forearms, about the umbilicus, on the nipples of females 
and the genitals of males ; that scratched papules and 
pustular lesions are more characteristic of it than vesi- 
cles, and that it presents the pathognomonic furrows, we 
should not confound it with impetigo contagiosa, which 
has none of these symptoms. Further, impetigo will, in 
almost all cases, occur upon the face at the same time as 
upon the hands, and that location is very rarely attacked 
by the itch mite. 

The diagnosis from pemphigus is by no means always 
easy. The occurrence of the bullous form of contagious 
impetigo is so rare that it is no wonder it is mistaken for 
pemphigus. Indeed, it is probable that not a few of the 
cases reported as acute pemphigus in children, which pos- 
sessed apparent contagious qualities, were instances of 
this bullous form of impetigo. The diagnosis between 
the two diseases can scarcely be made with certainty by 
the appearances of the bullae alone ; we must also take 
into consideration the general course of the disease. The 
differential diagnosis may be given as follows : 

Pemphigus. Impetigo Contagiosa. 

(Bullous form). 

1. Occurs chiefly in adults. 1. Occurs chiefly in children. 

2. No source oi contagion can be 2. A source of contagion can usu- 

found. ally be found. 

3. No particular sites of prefer- 3. Met with most often upon the 

ence ; if any thing, it is most trunk ; sometimes it may oc- 

frequent on the extremities. cur on the face, hands, or ex- 

tremities. 

4. Chronic in its course ; marked 4. Acute in its course, rarely last- 

by frequent relapses ; may re- ing more than a few weeks, 

turn from year to year. 

5. Bullae are fully distended with 5. Bullae not fully distended, but 

a clear fluid, so that their flaccid, and contain sero-puru- 

covers appear tense. They of- lent fluid. They may have a 

ten spring up out of the sound well-marked red halo while 

skin without areola. slowly attaining tbeir full size. 

Characteristic vesico-pustules 
are generally present else- 
where at the same time. 

6. Lesions often occur in great 6. Lesions few in number, do not 

numbers, so as to cover the involve the whole body, and 

whole body, and at times are itch but little, if at all. 
pruriginous. 

7. Disease obstinate to treatment, 7. Disease yields readily to treat- 

and prognosis usually grave. ment; prognosis uniformly good. 



376 DISEASES OF THE SKIK 

Ecthyma is probably only a form of impetigo conta- 
giosa that occurs in broken-down subjects. It affects by 
preference the lower extremities, is seen most often in 
adults, and its lesions are deep pustules which are highly 
inflammatory and painful. 

Treatment. The treatment of the usual form is to 
direct the affected parts to be scrubbed with warm water 
and soap to remove the crusts, and covered with a 5 
per cent, carbolized vaseline, or with oxide of zinc oint- 
ment with carbolic acid in the same strength, or with the 
ointment of the ammoniate of mercury diluted one-half. 
The last is the best. If there is a good deal of crustiug, 
the crusts may readily be removed by soaking them with 
oil or warm water, after which the applications mentioned 
may be made. Salicylic acid may be used in ointment 
in 3 to 5 per cent, strength. When there is an eczema 
complicating matters Lassar's paste answers all indica- 
tion. In the bullous form it is well to prick the bulla} 
at their most dependent part, and let the fluid escape, 
after which the lesions may be treated as just indicated. 

Prognosis. The prognosis of impetigo contagiosa is 
always good ; so readily is it cured that the patieuts sel- 
dom present themselves a third time for advice. 

Impetigo Granulata. See Pediculosis. 

Impetigo Herpetiformis. This disease was first de- 
scribed by Hebra 1 in 1872. 

In this country it is exceedingly rare, only a few cases 
having been reported. It is from Kaposi 2 that the ac- 
count here given is taken. 

The disease begins with an eruption of pustules in the 
genito-crural region, about the umbilicus, on the breasts, 
and in the axillae ; later upon various other locations. 
The pustules are crowded together, grouped, piu-head 
size, with at first opaque and later greenish-yellow con- 
tents. They dry into a dirty -brown crust, while imme- 

1 Wien. med. Wochenschr. , 1872, No. 48. 

2 Pathologie und Therapie der Hautkrankheiten. 



KELIS. 377 

diately around them new pustules appear in double or 
threefold circles, by the drying of which the crust is en- 
larged. The disease spreads by the growth of the indi- 
vidual groups and by the coalescence of neighboring ones. 
Underneath the crusts the skin appears red and covered 
with new epidermis ; or deprived of epidermis, moist, 
infiltrated and smooth ; or papillary, but never ulcerated. 
Within three or four months the whole cutaneous surface 
is involved, swollen, hot, covered with crusts, showing 
torn and excoriated places, with here and there circles 
of pustules. The mucous membrane of the tongue may 
show circumscribed gray patches. There is a continuous 
remittent fever, and each outbreak of pustules is marked 
by chills, high fever, and dry tongue. Nearly all cases 
prove fatal. The disease has affected almost exclusively 
pregnant women, few men having been reported with 
the malady. Delivery has not stopped the course of the 
disease. It is probably of septic origin. 

Diagnosis. The disease is stated by Kaposi to differ 
from dermatitis herpetiformis in being only pustular ; in its 
peculiar location and manner of spreading ; in the absence 
of itching ; in the severe constitutional symptoms ; and in 
its lethal ending. 

Treatment. No treatment has proved successful. 
We can only do our best to nourish the patient ; and by 
means of baths, dusting powders, or alkaline lotions, 
render her as comfortable as possible. 

Induratio Telae Celluloses Neonatorum. See Sclerema 
neonatorum. 

Inflammatory Fungoid Neoplasm. See Mycosis fun- 
goides. 

Intertrigo. See Erythema intertrigo. 

Iodic Acne. See Dermatitis medicamentosa. 

Itch. See Scabies. 

Jacob's Ulcer is an epithelioma. 

Juckblattern. See Prurigo. 

Kelis. See Keloid. 



378 DISEASES OF TEE SKIN. 

Keloid. Synonyms : Kelis ; (Fr.) Cancer tubereux, 
Cheloide ; (Ger.) Knollenkrebs. 

A connective-tissue new growth in the skin, occurring 
most commonly upon the chest ; characterized by hard- 
ness, by a pinkish color, and by sending off prolongations 
in all directions. (Fig. 50.) 

Fig. 50. 




Keloid, l 



Symptoms. It is usual to divide keloids into two 
varieties, one of which is called the true or spontaneous 
keloid, and the other the false or secondary keloid the 
result of injuries. Of late the opinion is gaining ground 
that no such distinction can be made, and that even the 
true keloid results from some slight injury. As most 
commonly met with, it consists of a single, firm, hard, 

1 From G. H. Fox's Photographs of Skin Diseases. 



KELOID. 379 

pinkish, freely movable, oval or elongated, elevated tumor 
upon the upper half of the sternum, from which claw-like 
processes are given off in all directions. While there may 
be but one tumor, the lesions may be multiple, there 
being either one large and several small ones upon the 
chest, or many scattered over the body. They begin as 
small pinkish elevations and gradually enlarge until they 
attain a certain size, when they may remain stationary or 
else slowly grow. They assume all sorts of shapes and 
sizes. Sometimes they have an even surface, sometimes 
they are nodular. They may be quite small, or they may 
be so large as to run nearly half-way across the chest. 
Then the appearance is as if the skiD were drawn up 
into the tumor. The epidermis is smooth over them, and 
the pink color is due to dilated bloodvessels. Sometimes 
the color is white. Though they are rarely met with on 
the face of the white races, they are very common upon 
the face of the negro. They are often attended by a 
good deal of pain, or pruritus, or pricking sensations. 

Beside this form of keloid, that may or may not be 
spontaneous, we have the evident scar keloids that occur 
over the site of an injury to the skin. These have fol- 
lowed syphilides that have destroyed the skin, variola 
pustules, psoriasis, a blister, or acne. 1 They may be 
limited to the site of the previous lesion or spread beyond 
it. This form of keloid is very often seen on the face of 
the male negro who shaves, the cheeks and chin being 
studded over with small, hard, white elevations. The 
hypertrophied scar resembles keloid, but never spreads , 
beyond the limits of the injury, has no claw-like pro- 
cesses, is not so pinkish nor so permanent. 

Keloids very rarely ulcerate or change into malignant 
growths. But it is not uncommon for epithelioma to de- 
velop on hypertrophic scars. 

Etiology. We know scarcely anything as to the 
cause of keloid, and can only beg the question by saying 
that it is a predisposition on the part of the skin. It is 
1 Purdon : Jour. Cutan. and Ven. Dis., 1882-83, i., 203. 



380 DISEASES OF THE SKIN. 

probable that some minute injury precedes the tumor. 
The negro race is peculiarly prone to the disease. Sex is 
without influence, and it may occur at any age, though 
rare before puberty and in old age. Histologically the 
structure of the keloid is similar to that of the cicatrix — 
that is, it is a dense fibrous connective-tissue growth 
which has its seat in the true skin. 

Treatment. As a rule, it is safest to leave the 
growths alone. Cutting them out is often disappointing 
in its results, as they are apt to return. Multiple scari- 
fications followed by the application of acetic acid have 
been successful. Leloir and Vidal 1 recommend follow- 
ing multiple scarifications with a boric-acid dressing. 
The next day mercurial plaster is to be applied, and 
changed every morning and evening. Perseverance in 
this method, they say, may result in a cure. Compres- 
sion by means of an elastic bandage or by mercurial 
plaster sometimes reduces the prominence of the tumors. 
Hardaway has succeeded in removing one keloid and two 
hypertrophied scars by means of electrolysis, and Brocq 
has commended the method. A stout needle must be 
used and multiple punctures made in all directions, and 
in the tissues for a space beyond the tumor. Galvanism 
is said to reduce hypertrophied scars. Balzer and Mous- 
seaux 2 recommend the use of a 20 per cent, solution of 
creosote in oil. A cubic centimeter of the solution is to 
be injected into many points until the tumor pales. This 
is followed by inflammation, swelling, and sloughing off 
of a portion of the keloid, and rather deep ulceration. 
After a few days the ulcerations are healed and the injec- 
tions are repeated. Andeer 3 recommends resorcin and a 
bandage. S. Tousey 4 advocates the use of thiosinamin, 
and reports some favorable cases. It may be used either 
hypodermically once a day or every other day, 12 to 15 

1 Ann. de derm, et de syph., 1890, i., 193. 

2 Ibid., 1898, ix., 1147. 

3 Centralbl. f. med. Wissenschaft, 1888, xxvi., 785. 

4 New York Med. Journ., 1897, lxvi , 624. 



KERATOSIS FOLLICULABIS. 381 

minims of a 10 per cent, solution in equal parts of pure 
glycerin and sterilized water ; or by the mouth, 3 grains 
being given during the day. I have tried this treatment 
in a number of cases without benefit. Unna recom- 
mends thiosinamin plasters. The use of x-rays has been 
followed by the disappearance of a number of keloids. 
Pusey advises daily exposures, or every second or third 
day, gradually carried to the point of producing an ery- 
thema unless the growth subsides. It takes from one 
to six months to remove them. Hypodermic injections 
of morphine, or the application of belladonna ointment, 
may be necessary to relieve pain. 

Prognosis. It is possible for hypertrophied scars to 
undergo spontaneous involution. This is especially the 
case in the scar keloid following syphilis. Usually this 
cannot be expected in true keloid. 

Keloid of Addison. See Morphoea. 
Keloid of Alibert. See Keloid. 
Keratoangioma. See Angiokeratoma. 
Keratodermia Excentrica. See Porokeratosis. 

Keratolysis Exfoliativa is the name applied by A. Sang- 
ster * to a case of congenital exfoliation of the skin which 
resembled ichthyosis, excepting that its scaling was more 
papery, like that seen in dermatitis exfoliativa. 

Keratolysis Neonatorum. See Dermatitis exfoliativa 
neonatorum. 

Keratosis Circumscripta. See Ichthyosis. 

Keratosis Diffusa seu Epidermica. See Ichthyosis con- 
genita. 

Keratosis Follicularis. This is a rare affection of the 
skin to which especial attention has of late been given. 
It is probably the same as was described by Guibout under 
the name of acnS sebacee coniee, and by Lesser as ichthy- 
osis follicularis. The French have named it psorosper- 
mose folliculaire vegetanle, but as this title was given it 

1 Brit. Journ. Dermat., 1895, vii., 37. 



382 DISEASES OF THE SKIN. 

by Darier and Thibault in 1889, under the idea that it 
was due to psorosperrns, which have been shown to be 
only degenerated epithelium, and as White x had already 
reported a case in 1889, as one of keratosis follicularis, 
it seems to me best to retain his title. 

Symptoms. The disease affects nearly the whole cu- 
taneous surface, though in White's case the palms and 
soles were free. It frequently is first seen on the face. 
The eruption begins as pinhead-sized papules, which are 
firm and of the color of the skin, looking like keratosis 
pilaris. As they increase in size they become hyperaemic ; 
still growing, they become hemispherical or flattened, 
with smooth or polished, dense adherent coverings of nail- 
like consistence, and varying in color from dull -red to 
purplish, dusky-red, brown, and brownish black. Some 
of them are excoriated by scratching and bear hemor- 
rhagic crusts. These lesions are discrete, and the skin 
about them normal. They are located in the hair 
follicles. In places the lesions run together and form 
elevated areas with uneven surfaces, covered by thick 
yellowish or brownish, flattened horny concretions; or 
there may be brownish or blackish plates. The patches 
feel rough and somewhat greasy. Here and there will 
be found papillomatous excrescences ; or enormously 
dilated follicular openings filled with comedo-like, firm, 
slightly projecting concretions forming hemispherical 
elevations, which when expressed are found to be hard 
and perfectly dry, leaving the follicle mouth patulous. 
It spreads gradually and in course of years it may become 
generalized. The nails become coarse, slightly thick- 
ened, and ragged at their free edges. Boeck 2 says that 
they are often the seat of a marked hyperkeratosis with- 
out a trace of the disease itself anywhere in their neigh- 
borhood. The hard palate in White's case showed some 
follicular elevations. Pruritus is marked in some cases. 
A fetid odor is given off from the patient. 

1 Journ. Cutan. and Gen.-Urin. Dis., 1889, vii., 201. 

2 Arch. f. Dermat. u. Syph., 1891, xxiii, 857, 



KERATOSIS FOLLICULABIS. 383 

Upon the scalp the disease appears for a long time as a 
seborrhoea sicca, but later the same elevations about the 
hairs can be made out as are seen upon the general integu- 
ment. Upon the back of the hands and fingers the erup- 
tion presents the appearance of simple papillary growths, 
little pale-white, slightly raised, confluent and adherent 
masses. Upon the palms and soles, instead of elevations, 
we find punctate depressions, and perhaps a hyperkeratosis. 
In the axillse, on account of maceration by sweat, the 
masses are not so hard and horny, and the scales can be 
rubbed off, when a moist, red, warty surface is exposed. 

The course of the disease is a progressive one by the 
springing up of new lesions. It develops symmetrically. 
It seems to have no damaging effect on the health. It 
affects specially the scalp, axillse, inguinal region, abdomen 
below the umbilicus, back of the hands and feet, and the 
wrists. 

Etiology. We know nothing positive about the eti- 
ology of this rare affection. White met with it in a father 
and daughter, and that would suggest the idea of heredity. 
The disease may begin at any age, cases having been 
reported as commencing in the first weeks of life, in the 
sixth, sixteenth, twenty-second, twenty-seventh, and 
thirty-sixth year, though most cases occur before the 
twenty-fifth year. Males are more often affected than 
females. 

Pathology. J. T. Bowen, who made a careful ex- 
amination of White's first case, says that "the disease is 
a keratosis of the epithelial lining of the mouths of the 
follicles, which, by extension downward, gradually pro- 
duces pouch-like depressions in the corium. The capacity 
for corneous metamorphosis is so great that the central 
portion becomes a firm horn, which by production of horny 
matter from below is gradually pushed out above the sur- 
face of the skin. There was no proof that the sebaceous 
glands were affected by the horny change." The keratosis 
may occur outside of the mouths of the follicles. 

Diagnosis. The disease differs from pityriasis rubra 



384 DISEASES OF THE SKIN. 

pilaris in lacking the constant and early involvement of 
the palms and soles ; in the absence of the isolated papules 
pierced by hairs on the dorsum of the fmgers ; and the 
extensive, diffused, scaly dermatitis of the face, neck, and 
other parts ; and in having horny plugs. It differs from 
acanthosis nigricans in not affecting the mucous mem- 
branes ; not having warty, deeply pigmented growths ; and 
not being associated with visceral disease. 

Treatment. The proper treatment is yet undeter- 
mined. It might be well to try the methods found 
useful in ichthyosis. It is always a very obstinate dis- 
ease, relapsing after the skin manifestations have been 
removed. X-rays have benefitted some cases. 

Keratosis Follicularis Contagiosa. This is a rare disease 
that was first described by Brooke. 1 

It is akin to keratosis follicularis, and some cases des- 
cribed as acne sebacee cornee. According to Brooke's 
description the first change in the skin is a thickening 
of the corneous layer so that there is an accentuation of 
the little rhomboid spaces of the skin. Minute black 
specks appear in them, some of which develop into pap- 
ules from the top of which spines protrude. The spines 
are long and thin like bristles ; others are short and thick 
like comedones. When extracted pit like depressions 
are left. These give the skin a rough, nutmeg-grater 
feel. Some of the larger papules become inflamed and 
resemble acne pustules, while others assume a warty ap- 
pearance. The lesions may aggregate into patches which 
are rough to the feel, the skin about them having a dirty 
yellowish-brown color. The disease is symmetrical and 
is found chiefly on the nape of the neck, the shoulders, 
and extensor aspects of the limbs. It may be found any- 
where on the body. 

Etiology and Pathology. It occurs most often in 
children and is contagious, spreading through a family. 
It is a hyperkeratosis affecting chiefly the follicles, and 
extending to the other epithelial layers. 

1 Internat. Atlas of Skin Diseases, 1892, part vii, plate xxii. 



KERATOSIS PALMABIS ET PLANTARIS. 385 

Treatment. Softening of the skin by an ointment 
containing an alkalic such as carbonate of soda, or potash 
will remove the lesions. Relapses may occur. 

Keratosis Nigricans. See Acanthosis nigricans. 

Keratosis Palmaris et Plantaris. This is a form of con- 
genital or acquired callositas. It has also been called 
keratoma palmare et plantare hereditarium, ichthyosis 
palmaris et plantaris, tylosis palmse et plantge. It is char- 
acterized by the appearance upon the palms and soles of 
masses of thickened skin of leathery consistence and yellow 
or brown color. They come without apparent cause, and 
usually show a symmetrical arrangement. The palms 
or the soles alone may be affected, but it is always both 
palms or both soles that are affected. There is sometimes 
a zone of redness about the thickened plates. Sometimes 
the whole palm or sole is covered, sometimes the horny 
masses occur in islands. The plates may be shed period- 
ically, only to reform. The surface of the plates may be 
smooth or uneven. Hyperidrosis is frequently marked. 
The nails at times show hypertrophic changes. Pain may 
be complained of when the hands or feet are used. If the 
feet are affected, the pain may be so great as to prevent 
walking. 

One form of the disease is due to the prolonged inges- 
tion of arsenic. It occurs in a number of isolated points 
over the palms and soles. 

Etiology. The disease is hereditary in many in- 
stances, and congenital, and like ichthyosis tends to affect 
only one sex in the family. We do not know its cause, and 
we class it as a tropho-neurosis. It sometimes has been 
noted to follow the prolonged ingestion of arsenic. Its 
pathology is the same as that of callositas. 

Treatment. The plates may be removed by salicylic 

acid plaster or ointment, 10 to 20 per cent, strength. 

The same end is reached by poultices, the wearing of 

rubber sheeting, and the application of various plasters. 

25 



386 DISEASES OF THE SKIN. 

A permanent cure can hardly be expected. In some cases 
arrays have removed the thickening. 

Keratosis Pigmentosa. See Verruca senilis. 

Keratosis Pilaris. Synonyms : Lichen pilaris ; Pity- 
riasis pilaris ; Ichthyosis seu hyperkeratosis follicularis ; 
Cacotrophia folliculorum ; (Fr.) Xerodermic pilaire, Ich- 
thyose anserine des scrofuleux. 

Symptoms. As its name indicates, this is a disorder 
of cornification. It is characterized by a heaping up of 
the corneous cells about the mouths of the hair follicles 
in the form of small conical, whitish or grayish elevations. 
Between them the texture of the skin is normal ; its color 
may be unchanged or rosy, or of a grayish or brownish 
shade. It occurs chiefly upon the extensor surfaces of 
the limbs, especially upon the upper arm and thigh, but 
may occur anywhere. The appearance of the affected 
part resembles cutis anserina, being dotted over with pin- 
head- to small-pea-sized papules, each one of which is 
either pierced by a hair or has a black dot at its summit 
indicating the mouth of the hair follicle. The papules 
are often scaly. The hair is either normal, broken off, 
or only to be found by opening the papule, when it will 
be seen curled up inside of it. The skin feels dry and 
harsh. There may be slight pruritus. Pityriasis capitis 
may be present at the same time. As the disease is at- 
tended by but slight, if any, subjective symptoms it is 
often overlooked. It is a chronic affection in most cases. 

Brocq describes a keratosis pilaris of the face begin- 
ning as minute scaly papules about the hairs, which crowd 
together to form patches and give a rosy or red tint to 
the skin. After a time the disease seems to destroy the 
follicle, and we find depress3d scars arranged in rows or 
scattered about on the red patch. This bears some re- 
semblance to lupus erythematosus, and is the ulerythema 
ophryogenes of Taenzer. Besnier describes a somewhat 
similar condition as occurring upon the extremities. 

Etiology. The disease is sometimes congenital and 



KERATOSIS SENILIS. 387 

often forms a part of ichthyosis. It is most common in 
women, and those who do not bathe frequently, or in 
whom there is cutaneous inactivity, or a peculiarly coarse 
quality of skin. 

Pathology. The lesions are due to a hyperkeratosis 
about the hair follicle mouths which heaps up so as to 
form the papules. There may be slight inflammation 
about the base of some of the papules. 

Diagnosis. It differs from cutis anserina in being a 
permanent condition; from the miliary papular syphilide 
in being whitish, grayish, or blackish, and not dark-red 
or raw-ham color, and in being removable by soap and 
water. Lichen scrofulosorum occurs in strumous subjects 
and in well-marked circular or crescentic patches, which 
is foreign to keratosis. Papular eczema differs in being 
very itchy, and in having red inflammatory lesions. Ich- 
thyosis is a general affection of congenital origin, has pe- 
culiar markings of the skin, and is not limited to the 
hair follicles. Lichen pilaris (Crocker) has red papules 
at the beginning, spiny plugs, and occurs in patches. 

Treatment. The vigorous use of green soap and 
water in an alkaline bath, followed by oil or vaseline, 
will remove the evidences of the disease. Vapor or 
Russian baths may be used for the same purpose. Hyde 
prefers general cool baths containing \ of a pound of 
common salt to each gallon of water, after taking which 
the skin is to be rubbed with a coarse towel or flesh- 
brush. As the affection is allied to ichthyosis, it may be 
treated on the same plan, a new course of bathing being 
taken with each relapse. 

Keratosis Senilis. This malady may occur as a slight 
thickening of the corneous layer of the skin in the form 
of thin, dirty or brownish-gray plates, bean size or larger, 
which are adherent to the skin, but at first can be readily 
rubbed off, leaving a moist or oily surface. They soon 
reform, and in course of time, if frequently rubbed off, 
it will be noticed that the base shows small bleeding- 



388 DISEASES OF THE SKIN. 

points, later a superficially ulcerated surface, and still 
later all the signs of an epithelioma. 

Or it may take the form of warty outgrowths, of dirty 
color, which are hard, and when picked off crumble in 
the fingers. These also in course of time if frequently 
removed undergo epitheliomatous changes. Both forms 
may be more or less greasy in character. Their first 
state may be a lentil sized or larger pigmentary patch. 
They are most often located on the face or the backs of 
the hands, locations most exposed to the action of sun- 
light. 

Etiology. Senility of the skin is the cause of the 
disease. While they occur most often after sixty years 
of age, they may occur at a much earlier age, at any 
time after middle life. It is probable that lack of care 
of the skin, and exposure to the sunlight are active 
causes in their production. It is said that they are seen 
in farmers and out-door workers in the country more com- 
monly than in city dwellers. Repeated irritation from 
attempts at rubbing them off changes them into epithe- 
liomas. 

Treatment. When small and when they are com- 
paratively young they may be removed by the use of an 
ointment containing 1 to 5 per cent, of salicylic acid, to 
which may be added precipitated sulphur in like amount. 
If they are hard they had best be let alone, or treated as 
if they were epitheliomas by currettage and caustics, or 
x-rays. It must be borne in mind that the senile skin 
bears the rays badly, and they must be used with caution. 

Kerion. Synonyms : Trichomykosis capillitii ; Tinea 
kerion ; Kerion Celsi. 

Symptoms. This is a more or less chronic inflamma- 
tion of the scalp or beard that most often is a form of 
ringworm, but may be produced quite independently of 
that disease. It is most commonly seen on the scalp. 
The affected part becomes red, oedematous, swollen, and 
boggy, and may assume a purplish color. Its surface is 



KERION. 389 

glazed, uneven, and studded with a number of yellowish 
suppurating points, or with foramina out of which oozes 
a sticky, viscid, gelatinous, transparent fluid. Sometimes 
suppuration may occur attended with a sero-purulent dis- 
charge. The swelling is round or oval in shape, and 
varies in size ; it may be but one or two inches in diam- 
eter, or as large as a turkey's egg. The pustules form 
about the hair in the early stage ; later the hairs fall and 
the discharge takes place from the openings of the hair 
follicles. If the tumor is opened, a thick, viscid ma- 
terial escapes. If the disease occurs with ringworm, the 
hair will be broken off. Permanent baldness may re- 
sult if the inflammation is* intense. There are more or 
less pain and tenderness, and at times itching and burn- 
ing. The posterior cervical glands may be enlarged. 

Etiology. The disease is comparatively rare. It 
occurs chiefly in children of poor constitution. It is 
most commonly due to the trichophyton fungus passing 
deep down into the hair follicles, but may be caused by 
the application of irritants to the scalp, or follow eczema, 
favus, or sycosis of that part. 

Diagnosis. Kerion must be diagnosed from an abscess, 
a papilloma, a gumma, and a sebaceous cyst. An abscess 
is not preceded by ringworm, has no history of an irritant 
applied to the scalp, and may arise without any antece- 
dent disease of the scalp ; it is more painful ; it is often 
accompanied by a sensation of throbbing, by chilliness, 
fever, and general malaise ; when fully formed there is 
fluctuation, and when opened it gives exit to pus. These 
symptoms are not met with in kerion. A papilloma is 
non-inflammatory, firm to the touch, and is unaccom- 
panied by a discharge. A gumma is usually accompanied 
by other signs of syphilis, and tends to break down and 
ulcerate. A sebaceous cyst is slow iu its growth, the skin 
over it is normal, there is no discharge, and when opened 
it gives vent to a cheesy mass. A fatty tumor is a chronic, 
elastic, freely movable swelling, with normal skin over it. 

Treatment. In treating a case epilation should be 



390 DISEASES OF THE SKIN. 

performed in order to save the hair and give exit to the 
discharge. If some irritant application is the cause, that 
should be discontinued, and hot-water dressings, antiseptic 
solutions, or mild emollient applications employed. If 
the cause is ringworm, the remedies proper for that disease 
should at once be used. What they are will be found 
under Trichophytosis capitis. 

Kleienflechte. See Chromophytosis. 
Kohlenbeule. See Carbuncle. 

Koilonychia or Spoon Nails is a condition of the nail in 
which it becomes more or less concave from side to side, 
sometimes antero-posteriorly. The nail is thin and easily 
bent, its surface is furrowed, and its free border irregularly 
notched. Its color is whitish, its edge being dirty-gray. 
It begins on one finger and gradually affects all the nails. 
It is often associated with leuconychia. The nails are 
easily broken. There is often a subungual keratosis at 
the free borders of the nails. It is a chronic disease, and 
may be hereditary ; or acquired, as from having the hands 
much in water. 

Kopskurv. See Favus. 
Knollenkrebs. See Keloid. 
Kratze. See Scabies. 

Kraurosis Vulvae is a name proposed by Breisky 1 for a 
form of atrophy of the skin of the external genitals of 
women, which may occur at any age. The disease has its 
seat in the vestibule, the labia minora with the frenulum 
and prseputium clitoridis, the inner surfaces of the labia 
majora up to the posterior commissure, and the contiguous 
skin of the perineum. It gives rise to the appearance of 
a defect in the development of the normal folds of the 
vulva. At times the labia minora and the prseputium 
clitoridis are apparently wanting. The affected skin is 
white and dry, the epidermis is often thickened, and tel- 
angiectasic vessels are visible. Stenosis of the vulvar en- 

i Zeitschrift f. Heilkunde, 1885. 



LENTIGO. 391 

trance may result, and thus obstruction be offered both to 
coitus and parturition. The cause is obscure ; possibly a 
long-continued blennorrhea, or a congenital defect, or a 
process analogous to leucoplakia buccalis. Treatment is 
of no effect. 1 

Krebs is the German for cancer. 
Kupferfinne. See Rosacea. 
Kupferrose. See Rosacea. 
Kupfriges Gesicht. See Rosacea. 

Kwe-na. A disease occurring in Burmah and said to 
be the same as Yaws. 

Larva Migrans. See Hyponomoderma. 
Lausesucht. See Pediculosis. 
Leberflecken. See Chloasma. 
Leichdorn. See Clavus. 
Leiomyoma Cutis. See Myoma. 

Lentigo. Synonyms : Ephelides ; (Ger.) Sommerspros- 
sen, Linsenflecke ; Freckles. 

Freckles are properly a species of chloasma. They 
occur as light to dark-brown or even black macules, and 
are usually located upon exposed parts, especially the face 
and back of the hands, but they may occur anywhere. 
In size they vary from that of a pinhead to that of a split 
pea. They give rise to no subjective symptoms. They 
usually do not appear before the eighth year of life, but 
congenital cases have been reported. The latter should 
rather be classed among the pigmentary nsevi. A division 
is sometimes made between those w T hich are permanent and 
occur upon unexposed places and those which occur in 
summer to disappear in winter. To the former the name 
lentigo is given, and to the latter ephelides. The dis- 
tinction is not worth preserving. As old age is ap- 
proached freckles no longer form, and the old ones are 
apt to disappear. 

Lentigo maligna is a form of lentigo that comes in old 
age in the form of dark -brown small irregular spots of 
1 Janovsky : Monatshefte f. prakt. Dermat., 1888, vii., 951. 



392 DISEASES OF THE SKIN. 

pigment that occur on the eyelids, and even the conjunc- 
tiva, and coalesce into patches which later may change into 
an epithelioma. 

Etiology. The cause of freckles is probably an in- 
born peculiarity of the skin. It has been advanced as a 
theory of their production that they are due to the chem- 
ical action of the sun's rays upon the blood. Blondes are 
more prone to them than are brunettes. Many people 
never freckle. Symptomatically they occur as part of 
atrophoderma pigmentosum. 

Pathology. Freckles are but circumscribed deposits 
of pigment. Cohn x has endeavored to show that leuti- 
gines differ from ephelides in being discrete, slightly ele- 
vated, and having their pigment in all the layers of the 
epidermis, as well as in the cutis, and in being associated 
with changes in the bloodvessels of the cutis ; while 
ephelides are crowded together, their pigment is only in 
the basal layer of the epidermis, and there are no changes 
in the bloodvessels. 

Treatment. The treatment of freckles is the same 
as that of chloasma. The only prevention is to protect 
the skin from the action of the sunlight by wearing veils 
or by the use of some lotion containing a pigment, such 
as calamine lotion. Hardaway recommends for their re- 
moval the following : 

R Hydrarg. ammon., | - - ^ -- 4 | 

Bismuthi subnitrat., j 
Ungt. aq. rosae, ad 3J ; ad 32 [ M. 

He speaks highly also of electrolysis for the removal 
of very black freckles. Bulkley recommends the fol- 



ing 






R 


Hydrarg. bichlor., 


gr- vj; 




Acid, acetic, dil. , 


3ij; 




Ac. boric, 


gr. xl; 




Aquae rosae, 


ad giv; 



8 

2 

ad 128 



M. 



This is to be used night and morning, at first gently, but 
afterward to be well rubbed in. The skin may be caused 
1 Monatshefte f. prakt. Dermat., 1891, xii., 119. 



LEPRA. 393 

to exfoliate superficially by dabbing on the skin two or 
three times a day an aqueous solution of bichloride of 
mercury, \ to 4 grains to the ounce. As socn as scaling 
begins the lotion should be discontinued. Stelwagon 
prefers 

R 



Hydrarg. bichlor., gr. iv-viij ; 


0.26-0.52 


Tinct. benzoin., oij > 


8. 


Zinc, sulphat., gr. xx-xl, 


1.33-2.65 


Alcohol, 




Aquae, aa ad 5iv; 


128. 



M. 

used in the same way. Peroxide of hydrogen bleaches 
them. They may also be touched with dilute acetic or 
lactic acid, or with pure carbolic acid. 

There is hardly any use in endeavoring; to cure freckles 
occurring from the action of the sun, as they depart of 
themselves. 

Lentigo Maligna. See Atrophoderma pigmentosum 
and lentigo. 

Leontiasis. See Leprosy. 

Lepothrix. This is a condition of the hairs of the 
axillae and scrotum which presents itself as diffuse or 
nodular incrustation of the hair, which is composed of a 
parasitic growth. The hairs are not diseased, but simply 
form a ground for the growth of the parasite. If the 
disease is very pronounced, the cortex of the hair may 
be damaged, or the fibres of the whole shaft may be broken 
up. It is met with in those who sweat freely. Sometimes 
the masses are red. They may be removed with soap and 
water, and prevented by the use of a mild antiparasitic 
lotion, such as boric acid. 

Lepra. Synonyms : Elephantiasis Grsecorum ; Leonti- 
asis ; Satyriasis; Lepra Arabum; (Fr.) La Lepre; (Ger.) 
Der Aussatz ; (Norweg.) Spedalskhed ; Leprosy. 

A chronic, endemic, constitutional disease due to in- 
fection by a specific bacillus ; characterized by anaesthe- 
sia, erythematous patches, tubercles, ulcerations, atro- 



394 



DISEASES OF THE SKIN. 



phies, and deformities according to the structures most 
affected • and ending in death. (Fig. 51.) 



Fig. 51. 




Tubercular and anaesthetic leprosy. i 

Symptoms. It is usual to describe three forms of lep- 
rosy — the tubercular, the maculo-ansesthetic, and the 
mixed. This is convenient for clinical purposes, though 

1 From a photograph kindly loaned me by Dr. P. A. Morrow, of 
New York. 



LEPRA. 395 

not absolutely correct, as even in the nearly pure tuber- 
cular form there is more or less anesthesia. All forms 
exist iu all endemic regions, but now one and now another 
form predominates. The tubercular form is the one most 
common in cold countries, the anaesthetic in hot countries. 
Morrow, 1 however, found that in the Hawaiian Islands 
the tubercular form constituted one-half of the cases, 
while the anaesthetic form formed but one-third of them. 
Tubercular leprosy. Sometimes this form appears sud- 
denly without prodromata, but usually for days, weeks, or 
months before the disease frankly declares itself the patient 
is out of health. He feels indefinitely ill, depressed, and 
listless ; he has dyspepsia and diarrhoea ; he is weak, 
chilly, and suffers from profuse sweating. There may be 
nose-bleed. Then a remittent fever of malarial type ap- 
pears. This fever may occur without the other prodro- 
mata, aud may recur with each new outbreak of tubercles. 
After a time an erythematous eruption appears upon the 
face, ears, the forearms, and thighs. It consists of purplish 
or mahogany-red, slightly raised, hyperaesthetic, smooth, 
shiny patches, of one or several inches in diameter, usually 
of oval form. The eruption may fade entirely away, to 
appear again with a fresh outbreak of fever. After some 
three to six months of the exanthem the tubercles appear, 
either upon the sites of the pre\ious lesions, or quite in- 
dependently of them. They begin as pinhead-sized pink 
papules that enlarge to split-pea- or even to hen's-egg- 
sized, yellowish -brown tubercles. If a number of these 
run together, large infiltrated patches are formed of irregu- 
lar shape and nodular surface. Then infiltrations may 
also arise by an increased deposit of leprous material in 
the macules, for the macules themselves are formed of 
leprous material, and are not simply erythematous lesions. 
Sometimes the infiltrated patches that arise from the 
macules may assume ring shapes, by clearing up in their 
centres. The tubercles are completely anaesthetic. They 

i New York Med. Journ., 1889, 1., 85. 



396 DISEASED OF THE SKIN, 

may come anywhere, but are most commonly seen in the 
eyebrows, lobes of the ears, the face generally, and upon 
the extremities. They are rare on the glans penis, palms, 
and soles. The scalp is said never to be affected. The 
mucous membranes of the mouth, nose, larynx, trachea, 
uterus, and vagina are also involved, as may be the con- 
junctivae. The tubercles may undergo spontaneous invo- 
lution in one place, while fresh outbreaks of them occur 
in other places. Or they may soften and break down and 
form leprous ulcers, which are indolent, sharply defined, 
and glazed over with a mucous discharge of a peculiar 
odor. These may attain enormous dimensions, becoming 
serpiginous and phagedenic. When these ulcers go deep, 
as they may do on the lower extremities especially, there 
may take place spontaneous amputation of the fingers, 
toes, or whole members. This is one form of mutilating 
leprosy, which is most frequently encountered in the 
anaesthetic form of the disease. Or the tubercles may, 
on disappearing, leave atrophic spots. Their develop- 
ment and involution are always slow. 

The appearance of a well-developed case is striking. The 
face is deformed by the tubercles, and assumes the " leo- 
nine " expression on account of the thickening of the eye- 
brows causing them to protrude, so that the eyes are sunk- 
en and have a stern expression. The hair is wanting in the 
eyebrows. The immense lobes of the ears hang down. 
The lips protrude and are often everted. Tubercles stud 
the face. The forearms are enlarged and knobby. The 
hands are deformed. There is very commonly a discharge 
from the nose, a disagreeable odor from the mouth, and the 
sense of smell is lost. The eyesight is often lost ; the voice 
is cracked and croaking. The lymphatic glands are often 
swollen. Happily, both in men and women sterility is 
the rule. There are commonly atrophy of the testicles 
and loss of sexual power in men. The disease is steadily 
progressive, and death occurs in eight years on an aver- 
age, though the disease may last for many years. Crocker 
says 40 per cent, die of the disease itself, 40 per cent. 



LEPRA. 



397 



die from renal or lung complications, and the rest from 
diarrhoea, anaemia, or general marasmus. 

Maculo-ancesthetic leprosy announces its onset not by 
febrile symptoms, but by shooting, lancinating pains in 
the chief nerve-trunks, as the ulnar, median, peroneal, 
and saphenous. There are also pain and tenderness in 

Fig. 52. 






Macular Leprosy. 



various places, and a state of general hypersethesia. 
Itching is regarded by Morrow as being one of the most 
common and characteristic prodromata of this form of 
leprosy. There may also be symptoms of general malaise 
and digestive disturbances. A frequent early symptom 
is a vesicular or bullous eruption upon the fingers and 
"Goes, with at first serous, then purulent contents. These 



398 DISEASES OF THE SKIN. 

may burst and leave a white, shining, anaesthetic spot, 
or an ulceration that heals with an anaesthetic cicatrix. 
Numbness soon follows the hyperaesthetic state. The 
patient cannot grasp things firmly, and the consequent 
unskillfulness of his action may be the first thing to 
attract his attention. This shows muscular weakness as 
well as numbness. 

After some months of these prodromal symptoms an 
eruption of macules similar to those of the tubercular 
variety appears upon the extremities, face and back. 
They are isolated, of oval shape, hardly raised above the 
surface, and of a pale-yellow to reddish-brown color* 
These often enlarge peripherally and clear up or become 
atrophic in the centre. Sometimes, instead of being oval, 
they will take the form of wide streaks or of gyrate figures. 
They are often hyperaesthetic when newly formed, but 
always perfectly anaesthetic when they have become 
atrophic, and even before that in cases that have lasted 
some little time. The large nerve-trunks, as that of the 
ulnar, are at first hyperaesthetic, but later are anaesthetic 
and can be felt like a whip-cord and rolled about under 
the finger without giving rise to pain. Anaesthetic areas 
will be found independently of the macules and in old cases 
a rather general anaesthesia develops, so that the patient 
may burn himself without noticing it. The anaesthetic 
areas are subject to change from time to time. Solitary 
bullae appear from time to time, as well as urticaria-like 
lesions. Marked atrophy of the muscles, of the hands 
and feet occurs, and paralysis of the extensor muscles of 
the second and third phalangeal joints. Wasted inter- 
ossei muscles and permanent flexion of the last phal- 
anges of the fingers give as characteristic an expression 
to the hand in this form of leprosy as the tubercles 
do to the face in the tubercular form. After some 
ten years or so, during which the greater part of the 
cutaneous surfaces may have become studded over with 
white, wrinkled, hairless, atrophic spots, the permanent 
stage is reached. During these years painless amputation 



LEPRA. 399 

of many of the joints may have occurred by a process of 
dry gangrene (Lepra mutilans). Erysipelas may occur. 
The nails and hair are shed. Sleeplessness may prove 
a distressing symptom. Loss of sexual power and ster- 
ility are manifest late in the disease. There is a marked 
anaesthesia of the soft palate, uvula, and pharynx. This 
form lasts much longer than the tubercular form, fifteen 
years being an average duration. Sometimes a fair 
degree of health is preserved for a much greater length of 
time. In most all cases more or less hebetude of mind 
is marked, becoming more pronounced with the duration 
of the disease. 

The mixed form is a combination of the symptoms of 
the two former varieties, and perhaps is the one most 
commonly met with in this country. Indeed, it is the rule 
that all tubercular cases present certain symptoms of the 
anaesthetic form, and vice versa, the variety being named 
from the prevailing lesion. 

Etiology. Up to within a few years various agencies 
were regarded as causes of leprosy, such as residence by 
the seashore, eating of putrid fish, heredity ; but in the 
light of our present knowledge there is but one cause, 
and that is contagion. The contagiousness of the disease 
is a strong plea for the segregation of the lepers within 
our own country. 

Leprosy is seen in both sexes, though the male sex is 
more often affected. It is rare in children, and is never 
seen in infants ; a strong argument against heredity. Its 
incubation stage is very long, reaching over a period of 
years. It occurs in all countries and climates, but is 
endemic in certain regions. It seems that a damp, cold 
climate, or a hot, moist climate favors the disease. Sporadic 
cases have been reported, but careful investigation would 
doubtless show that they had been exposed to contagion. 
Vaccination has been a carrier of contagion. 

Pathology. Constantly accumulating evidence points 
to the bacillus leprae as the disease carrier. This has been 
found in the tubercles* the infiltrations, the lymphatic 



400 DISEASES OF THE SKIN. 

glands, nerves, spleen, liver, walls of the bloodvessels, 
hair follicles, and sebaceous glands. It was discovered 
by Hansen in 1874, and since then has been studied by 
many pathologists. " This bacillus occurs as straight or 
very slightly curved rods, -g-^Vir °^ an mcn m length, which 
may have knob-shaped expansions at their ends or in 
their length, due to the presence of two to five spores." 
(Crocker.) Culture-experiments have for the most part 
failed, and inoculation-experiments have resulted nega- 
tively. The lepra nodule resembles, but is less vascular 
than ordinary granulation tissue. The epidermis is not 
involved. Just below the epidermis are seen the largest 
tumor cells. The youngest and smallest cells are at the 
base of the nodule. In the upper layers are found the 
so-called "globi," accumulations of degenerating cells, 
sharply circumscribed, and densely packed with bacilli. 

Diagnosis. In a fully developed case little difficulty 
in diagnosis can arise. Sometimes lepra will need to be 
differentiated from erythema multiforme; syphilis; lupus; 
inorphoea ; vitiligo, and syringomyelia. The presence of 
anaesthesia and the enlargement of the ulnar nerves in 
any doubtful case will establish the diagnosis of leprosy. 
Besides this, erythema runs a more acute course ; syphilis 
of the tubercular form presents redder tubercles, which 
ulcerate more rapidly, are grouped, and a history of syphi- 
lis is usually attainable ; the lupus tubercles are small, of 
apple-jelly color, soft, do not produce thickening of the 
eyebrows and nodular lobulation of the ears, and group 
themselves in patches in which cicatricial tissue will be 
found ; morphoea has a lardaceous appearance with a viola- 
ceous border ; vitiligo patches are more lead- white and 
sharply defined, while the skin is unaltered in texture 
and normal in sensation. 

Treatment. The best chance for recovery from leprosy 
is removal to a region where the disease is not endemic. 
This, with attention to hygiene, and a general tonic treat- 
ment, will do a great deal toward a cure. Quinine may 
be given during the febrile attacks. Of internal remedies, 



LEPRA. 401 

chaulmoogra oil holds the first rank, with an initial dose 
of 3 minims three times a day, and then gradually in- 
creased to as high a dose as the patient will stand. 
Nausea, vomiting, and diarrhoea show when this is reached. 
If given in milk of magnesia it will be better borne than 
in any other way. As this oil may cause fatty degen- 
eration of the liver and kidneys if given over too long 
a period, it is well to interrupt its administration from 
time to time. Gynocardic acid has sometimes been sub- 
stituted for it. G. H. Fox 1 has cured one patient by 
giving nux vomica or strychnine up to full constitutional 
effects, and then administering chaulmoogra oil continu- 
ously. Gurjun oil is also highly commended in an 
emulsion of 1 part of the oil and 3 parts of lime-water, 
of which the dose is J an ounce morning and night. 

Unna claims to have cured one case with sulpho-ichthy- 
olate of sodium from 6 to 45 grains a day, but others 
who have tried it have not had the same success. 
Salicylate of soda, 30 grains every four hours till 2 
drachms are taken ; salol in full doses ; thymol, 45 to 60 
grains a day ; carbolic acid up to 15 grains a day, are 
advocated by Lutz, Besnier, and others. The general 
health of the patient should receive attention, and symp- 
toms treated as they arise. H. R. Crocker 2 has had 
good results in one case by weekly and then semi- weekly 
hypodermic injections of \ of a grain of calomel in 20 
minims of oil. These were given for three months and 
then intermitted for three months. 

JExternally the chaulmoogra or gurjun oil maybe rubbed 
in. The ulcers are to be treated upon the usual surgical 
principles. Unna 3 recommends rubbing into all the lesions 
but those on the hands and face the following : 



li Chrysarobin., ") 

IchthyoL, / ^ iss ; aa6 



5 
M. 



Ac. salicyl. , gr. xl ; 2 

Ungt. simpl., ad ^iv; ad 128 

i Post-Graduate, 1885-6, L, 143. 

2 Lancet, 1896, ii., 334. 

3 Journ. Cutan. and Gen.-Urin. Dis., 1896, xiv., 413 
26 



402 DISEASES OF THE SKIN. 

On the face and hands he substituted pyrogallol for the 
chrysarobin. To counteract the bad effects of the drugs 
he administers 30 drops of dilute hydrochloric acid dur- 
ing the day. For women and children he substitutes 
resorcin for the chrysarobin. To old nodes, after pro- 
tecting the surrounding skin, he applies during five to 
seven days a plaster mull containing 20 to 40 parts of 
salicylic acid and 40 parts of creosote. 

The so-called Bhau Daji treatment * is said to have 
produced remarkable effects in from six to eight weeks 
after it was begun. It consists in the use of the oil of 
hydnocarpus inebrians, of which from TTL10 to §ss is 
taken in the morning in boiled milk. The patient is 
also anointed with the oil. Two hours afterward the oil 
is washed off in a warm bath. He is anointed on going 
to bed. He is not allowed to eat pork, beef, or fish, nor 
to drink alcoholics, tea, or coffee. He is fed on milk, 
fruit, vegetables, butter, eggs, mutton, and fowls. Poake 1 
advocates excision of the tubercles, followed by the ap- 
plication of pure carbolic acid. The thermo- and electro- 
cautery may be used to the same end. X-rays seem to 
exert a curative effect on the lesions. Segregation is the 
only preventive measure. 

Prognosis. The prognosis is bad, as the disease 
steadily progresses to a fatal termination unless the pa- 
tient can be removed from the endemic region. If he 
can be removed, there is a chance of staying the disease. 
In some instances the disease, even when the patient does 
not change his residence, pauses in its course for a long 
time ; but eventually it will again become active. 

Lepra Alphos. See Psoriasis. 
Lepra Arabum. See Elephantiasis. 
Lepre Vulgaire. See Psoriasis. 
Leprosy. See Lepra. 
Leucasmus. See Leucoderma. 
Leucokeratose. See Leucoplakia. 

i Brit. Journ. Dermat., 1893, v., 203. 



LEUCOPLAKIA. 403 

Leucopathia. See Leucoderma. 

Leucopathia Unguium, or Leuconychia. This affection 
consists in the appearance of white spots in the nail, which 
originate in the lunula, and gradually approach the free 
end of the nail as it grows forward. Sometimes these 
take the form of stripes or lines. Rarely the whole nail is 
affected. The nail-substance is otherwise unaltered. The 
spots are thought to be due to air-spaces in the nail-sub- 
stance. M. L. Heidingsfeld 1 believes that they are due 
to a disturbance in the growth, development, or keratini- 
zation of the matrix cells in their change to nail-struc- 
ture. Why these occur we do not know. Possibly there 
may be a process of fatty degeneration of the nerve-cells 
and subsequent absorption of the fat. (Taylor.) Or they 
may be caused by pressing back the nail-fold. They are 
common in the young, and coincident with white spots 
in the teeth. (Hutchinson.) They very often are noticed 
after fevers or other lowered conditions of health. Noth- 
ing can be done for this deformity except caring for the 
general health of the patient and stopping any bad habit. 

Leucoplakia. This is an affection of the mucous mem- 
brane of the tongue, lips, inside of the cheeks, and vulva, 
that has been described under the names psoriasis buc- 
calis, ichthyosis lingua?, leucokeratosis buccalis, and tylosis 
lingua?. It occurs in the form of ivory-white or bluish- 
white, glistening, irregularly shaped patches upon the 
mucous membranes that may be a little elevated. To the 
touch and tongue they feel rough. They may give rise 
to no discomfort, or they may interfere with chewing 
and speaking. They may be fissured or papillomatous. 
There is sometimes salivation. There is always danger 
of the development of carcinoma from them. They are 
caused by smoking, or occur in syphilis, psoriasis, lith- 
semia, stomachic or intestinal catarrh, diabetes, and dis- 
turbed nervous influences. Rubbing of the tongue 

1 Journ. Cutan. and Gen.-Urin. Dis., 1900, xv.= 490. 



404 DISEASES OF THE SKIN. 

against the sharp edge of a decayed tooth sometimes 
seems to cause them. It is thought by some that syphilis 
is at the bottom of all of them, it affecting the tissues in 
such a way that the various irritants incite the disease. 
Sometimes they arise without assignable cause. 

Diagnosis. Leucoplakia differs from the mucous 
patch in its more chronic course and slight tendency to 
ulceration. Lichen planus, when occurring in the mouth, 
resembles the disease very strongly, but takes the form of 
rings, festoons, and disks, and the typical lichen papules 
can be found on the skin. 

Treatment. It is very essential that tobacco be given 
up if the patient has been in the habit of using it. It is 
also necessary to address remedies to the cure or relief of 
any lithsemic or digestive disorder ; and to have the teeth 
put and kept in good order. The frequent use of normal 
salt solution as a mouth wash is advisable, combined with 
the application of balsam of Peru daily or every other day. 
An antisyphilitic treatment may be tried. It is said by 
some that the hypodermic administration of mercury is 
far better than the administration of the same drug by the 
mouth. Sometimes a patch may be removed by the daily 
application of pure lactic acid ; or \ per cent, solution of 
bichloride of mercury ; or 10 to 30 per cent, solution of 
salicylic acid; or 20 per cent, of chromic acid ; or 2 to 10 
per cent, of bichromate of potash; or by galvano- or 
actual cautery. S. Sherwell has had good success with 
the acid nitrate of mercury in 10 to 50 per cent, strength, 
according to the intensity of the process. Great care must 
be had in its use, the surrounding parts being protected by 
means of absorbent cotton, and an alkali held ready to 
neutralize any of the acid that has gone beyond the in- 
tended part, as well as to apply to the cauterized surface 
after a few moments. It is a very painful procedure. 
Hyde advocates the use of the dental burr after the injec- 
tion of cocaine. 

Prognosis. It is a very obstinate disease. Patches 
not infrequently take on a cancerous change. 



LICHEN OBTUSXJS CORNEOUS. 405 

Lichen Annularis. This affection is described by James 
Galloway * as occurring as small nodules in the neighbor- 
hood of the knuckles of the hands. The lesions form 
circular or crescentic patches that have a pale, ivory-like, 
elevated border raised from 1 to 2 millimeters. They 
are smooth and appear like deep-seated infiltration of the 
cutis. Inside of the border the lens shows that the normal 
wrinkles of the skin are partially obliterated. The disease 
advances at first slowly and then more rapidly. It is 
thought to be caused by some toxin, possibly that of gout. 
It is curable by tonics internally, and 2 to 10 per cent, 
salicylic acid externally. 

Lichen Circinatus. See Seborrhoea. 
Lichen Moniliformis. See Lichen planus. 

Lichen Obtusus Corneous. C. J. White 2 following 
Brocq, who first described the disease, gives the symptoms 
of this very rare malady as follows : 

The eruption consists in the appearance ou the skin of 
a number of globular lesions, from 3 to 10 mm. in diame- 
ter which are found most often on the upper and lower 
extremities, especially on the extensor surfaces. They 
begin as roundish, hemispherical papules, pinkish white 
in color, which slowly enlarge, and assume a brownish 
or rather deep cafe-au-lait tint. They are covered by a 
complete layer of fine, dry, grayish, very adherent scales, 
which become stratified, and later have a cornified appear- 
ance. The lesions are discrete and few, and develop with 
extreme slowness. The disease is very itchy, the patient 
scratching for relief until the horny tops of the papules 
are torn off. Then the lesions may present crater-form 
depressions, sometimes filled with blood crusts. Some 
of the papules have horny plugs in them. 

In White's case, the blood was found to coagulate in 
two minutes and fifty seconds, the normal time being one 

^rit. Journ. Dermat., 1899, xi., 221. 
2 Journ. Cutan. Dis., 1907, xxv., 385. 



406 DISEASES OF THE SKIN. 

minute and forty-five seconds. The calcium contents 
was 1 to 600, the normal being 1 to 1500. 

White regards the disease as the same as that described 
by Hardaway as, " Multiple tumors of the skin accom- 
panied by intense pruritus": and by Schamberg and 
Hirschberg as, " Multiple tumors of the skin in negroes 
associated with itching." Brocq was uncertain whether 
it was a form of lichen planus, or a pure neurodermatitis, 
but was inclined to the latter view. White's case im- 
proved under lactic acid internally, and chrysarobin 
externally. 

Lichen Pilaris. This term is usually used as a synonym 
of keratosis pilaris. But Crocker describes it as a separate 
disease, the lichen spiuulosus of Devergie. 

Symptoms. It develops acutely or subacutely in crops. 
It consists in an eruption of pinhead-sized, red, conical 
papules, in the centre of which is a horny spine pro- 
jecting about T *g- of an inch. These spines can be 
picked out, and leave a depression in the papule. After a 
time the redness subsides and the papule becomes the color 
of the skin. The papules are crowded together in patches, 
which are round, or large and irregular in outline. They 
occur in few or many regions and are symmetrically dis- 
tributed. The face, upper parts of chest, hands, and feet 
are usually exempt They give a nutmeg-grater sensation 
to the hand when passed over the patches. There is little 
or no itching. 

Etiology. Children are the chief subjects of the dis- 
ease, boys more often than girls. 

Diagnosis. It differs from keratosis pilaris in its 
spines, its inflammatory redness, acuteness of outbreak, 
and its patchy character. 

Treatment. Alkaline baths and linimentum saponis 
well rubbed in will cure the disease. If there is much 
inflammation, it is best to use an oil instead of the soap 
liniment. 



LICHEN PLANUS. 



407 



Lichen Planus. A chronic disease of the skin charac- 
terized by the eruption of smooth, waxy, angular, umbili- 
cated, red papules, that tend to form scaly, lilac-colored, 
elevated and infiltrated patches specially upon the flexor 
surfaces of the wrists and the inside of the knees. 

While the testimony from skilled observers is over- 
whelming that lichen planus papules may occur with lichen 
ruber, and while some cases of lichen ruber have developed 
after and together with lichen planus, still we see so many 



Fig. 53. 




Lichen planus. (Fox.i) 



cases of the latter occurring by itself that it merits a special 
description. In this country and in England lichen planus 
is far more frequent than is lichen ruber, and is regarded 
as a separate disease. While the latter occurred but 62 
times in 309,406 cases, the former occurred 918 times in 
the same number of cases, according to the statistics of the 
American Dermatological Association for 1897. 

Symptoms. The disease begins as an eruption of small 
purplish- or crimson-red, angular, flat, slightly raised 
papules, varying in size from y 1 ^ to | of an inch in dia- 
meter. The surface of the papules is smooth and shiny, 

1 G. H. Fox : The Skin Diseases of Children, New York, 1897. 



408 



DISEASES OF THE SKIN. 



" waxy-looking/' and they have a small depression in 
the centre. When fully developed the papules may have 
on them delicate gray striations, which are characteristic 
of the disease. The papules may remain discrete, and be 
disseminated over a larger or smaller area ; or they may 
arrange themselves in rows, or form rings, or aggregate 
themselves into patches, the single papules disappearing. 
The single papules are not scaly, the patches are slightly 
so, The patches may be small, and if so there is apt to 

Fig. 54. 






Lichen pianus. (Fox.) 

be a well-marked depression in their centre, and their 
shape is round or oval. The larger patches have no 
definite shape nor depression, but are well denned and 
elevated. Characteristic single papules will be found 
scattered about in the neighborhood of the patches. 
The color of the patches is characteristic, and may be 
defined as lilac. It is an important aid in diagnosis. 
The disease is very pruritic, and excoriations are often 
seen. Both the papules and patches on disappearing 
leave behind pigmented, slightly atrophic spots, which 
after a time, fade away. It is still a moot-point as to 



LICHEN PLANUS. 409 

whether the individual papule enlarges peripherally or 
not. Like those of psoriasis, the papules of lichen planus 
may appear upon scratched surfaces. 

The disease is most often met with upon the anterior 
surface of the wrists and forearms, and upon the inside 
of the knees, the former being the favorite location. But 
it may occur anywhere, other favorite locations being the 
flanks, lower part of the abdomen, and of the legs, and 
it may involve a large part of the body, though it rarely 
becomes general. The glans penis is at times affected, 
sometimes before the disease is seen elsewhere. If the 
prepuce is long the papules will be white like on the 
mucous membrane of the lips. If the glans is uncovered, 
the color of the papules will be the same as on the skin. 
The eruption has also been seen on the vulva. On the 
palms and soles there may be red, slightly hyperkeratotic, 
papular elevations that become confluent, and form irre- 
gular patches that may involve the whole palmar surface 
of the hands and fingers. The edge of the patches is 
sharply defined by a slightly raised border with, at times, 
a red zone on the outside. The palms feel like parch- 
ment and are of a brown color. When the nails are 
affected, they have on them either prominent elevations, 
like papules, forming vertical lines, or raised lines that 
run parallel to each other. The nails are rough, and at 
the free border of some nails there are corneous pads of 
brown color. The mucous membranes of the lips and 
mouth are affected, and the disease then disappears as 
white spots difficult if not impossible of diagnosis without 
the occurrence of the typical eruption on the integument. 
The involvement of the mucous membranes is rarely re- 
ported. It is probably more common than is supposed, 
because the mouth is seldom inspected, as the lesions give 
rise to no discomfort. As a rule, there is more or less 
symmetry shown in the disposition of the efflorescences ; 
and pruritus, which sometimes is marked. The general 
health is often unaffected, but, on the other hand, many 
of the subjects of the disease are not in perfect condition 



410 DISEASES OF THE SKIN. 

when the disease begins, and not a few others become 
greatly broken down on account of the loss of sleep and 
continual discomfort caused by the pruritus. The course 
of the disease is chronic, and new outbreaks are liable to 
occur. \ 

Fig. 55. 





Lichen ruber moniliformis. (After Taylor.) 

Kaposi * has described a unique form of this disease 
under the name of lichen ruber moniliformis, in w T hich the 
typical lesions became transformed into keloidal nodes 
arranged in lines. (Fig. 55.) The nodes were in some 
places as large as cherries with their bases confluent and 
their upper parts separated by furrows. Unna 2 described 

1 Vierteljahr. f. Dermat. u. Syph., 1886. xiii., 571. 

2 St. Petersburg, med. Wochenschr., 1884, i., 447. 



LICHEN PLANUS. 411 

under the name of lichen obtusus, a form of the disease in 
which the papules are midway between the acuminate and 
the plane. They are large and waxy, discrete, often convex 
frequently bluish-white, not scaly, and but slightly itchy. 
A lichen verrucosus and a lichen hypertrophicus have also 
been described. These are seen most often on the lower 
part of the legs and do not look at all like the usual erup- 
tion. They are elevated, warty, firm, violaceous, in irregu- 
larly shaped patches of various sizes. The gray striations 
are usually well marked on them. This form is specially 
obstinate to treatment. Hallopeau and others have re- 
ported cases in which angular flat papules of white color 
occur, under the name of lichen planus atrophicus, seu 
sclerosus, seu morphceicus. It is met with on the upper 
part of the chest and arms. White papules are seen in 
colored races. Lichen jjlanus striatus occurs as a long 
band, usually upon the inside of the thigh, sometimes ex- 
tending the entire length of the limb. Pemphigoid 
eruptions occasionally occur as part of the disease. 
Crocker, who at one time described an infantile form of the 
disease in which the papules come out acutely in groups, 
acuminate at first, but soon becoming flat, angular, and 
red, changing to purple, now regards it as merely a 
miliaria rubra. 

Etiology. We kuow no more about the causes of 
lichen planus than we do about those of lichen ruber. A 
neurotic element is marked in many of the cases, and 
cases have been reported in which the papules were dis- 
tributed along the course of a nerve. 1 Nervous exhaus- 
tion, rheumatic sweating, and checking perspiration are 
given as causes. Its subjects are mostly adults, many 
of them otherwise in good health. Many are care- 
worn or worried: It is probable that a toxaemia of 
some sort is the foundation of the disease. It is more 
frequent in women than in men in this country and in 
England, though in Austria the reverse obtains. 

Pathology. The nodule in lichen planus is charac- 
1 Mackenzie: Brit. Med. Journ., 1884, ii., 1077. 



412 DISEASES OF THE SKIN. 

terized, especially at the beginning, by the very pro- 
nounced hypertrophy of the rete niucosuni, and later, in 
lichen verrucosus, of the corneous layer. This latter is in 
the early stages composed of non-nucleated cells, though 
in the older lichens nuclei may be found. The stratum 
granulosum is also hypertrophied, but the eleidin irregu- 
larly divided, which gives the characteristic white and 
opalescent stripe and net-work formation. The papillae 
are broadened and infiltrated with round cells, and their 
vessels are dilated. The central point of the depression 
usually corresponds to the sweat duct orifice, the de- 
pression resulting from reabsorption and degeneration of 
the infiltration. The fact that the mucous membranes 
are affected is brought forward as an objection to the 
view that the process begins in the sweat duct. Robinson 
thinks that the process begins as an inflammation of the 
papillae and upper part of the corium. The form of the 
papule is determined by the shape of the so-called " skin 
fields." 

Diagnosis. An eruption of flat, shiny, angular, um- 
bilicated papules of a lilac color showing grayish stria- 
tions situated on the anterior surfaces of the wrists can 
be nothing but lichen planus. The same characteristics 
are diagnostic anywhere on the body, and sufficient to 
distinguish the disease from eczema and psoriasis. More- 
over eczema will show a tendency to moisture, or the 
papules will undergo change ; and psoriasis will be almost 
sure to have characteristic patches upon the elbows and 
knees, covered with more abundant white and ofttimes 
thick scales. Syphilis sometimes bears a strong resem- 
blance to lichen planus, but itching is less marked, its 
eruption is more polymorphous, and its color is more 
that of raw ham. 

Treatment. In the treatment of lichen planus, nerve 
tonics or sedatives and attention to the general health as 
well as to the hygiene both of the body and mind, are our 
most reliable agents. Arsenic is useful in some cases. 
Morris speaks highly of biniodide of mercury in the initial 



LICHEN PLANUS. 413 

dose of y 1 ^ of a grain, which is to be gradually increased. 
The protiodide of mercury, i to J of a grain three times 
a day, is useful in many cases. Antipyrine, phenacetine, 
and the spinal douche render good service. Alkaline 
diuretics sometimes do well, as the acetate of potash. 
Boeck and R. W. Taylor speak well of 15-grain doses of 
chlorate of potash fifteen minutes after eating, followed in 
a quarter of an hour by 20 drops of dilute nitric acid in 
a wineglassful of water. Crocker speaks highly of sali- 
cin, 15 to 20 grains three times a day, and of quinine. 
In obstinate cases change of scene in travel often cures 
when other measures fail. 

Locally, stimulants, such as tar, pyro<j(dlol, and chrys- 
arobin will prove serviceable. Stelwagon says that 
liquor carbonis detergens is the most efficient application. 
It is to be used at first diluted with 10 to 15 parts of 
water. If well borne the strength should be increased 
until it is used pure. It is to be dabbed on twice or 
more often daily. It may be used as an ointment of 10 
to 15 per cent, strength. TJnna's ointment, as given 
under lichen ruber acuminatus, is widely used. Touch- 
ing the papules with pure carbolic acid may be tried. 
In acute cases alkaline lotions will allay irritation. Thy- 
mol and naphtol may be tried as in lichen acuminatus. In 
chronic cases Hardaway recommends : 

R Saponis olivae praep., ^iv; 100 

Oleirusci, X - - ^ - - ^ 
Glycerim, j 

01. rosmarini, 3iss; 4 

Alcoholis, ad 5 viij ; ad 200 M. 

well rubbed in with a piece of flannel. The patches are 
sometimes favorably affected by mercurial plaster. Some 
cases in which the skin is very irritable are best treated 
by means of prolonged simple or medicated emollient 
baths. In the hypertrophic form salicylic acid plaster is 
useful. The patches may be curetted out. The x-rays 
also remove them. Pusey advises that they be used on 
alternate days, or less frequently, care being taken to 



414 DISEASES OF THE SKIN. 

avoid dermatitis. Iu generalized cases they relieve the 
pruritus, as also does the high frequency current. 

Peognosis. The prognosis is generally favorable, 
though the disease is often very obstinate. Relapses are 
not infrequent. 

Lichen Polymorphe Chronicuie. See Prurigo. 

Lichen Ruber Acuminatus. In this country this disease 
is rare, only 52 cases having been reported to the 
American Dermatological Association for sixteen years 
out of a total of 204,866. While in Europe lichen planus 
is considered as only a form of lichen ruber, in this 
country and in England it is regarded by probably the 
majority of the dermatologists as a separate disease. On 
account of the diversity in the descriptions of lichen 
ruber, the one here given is taken from Hebra and 
Kaposi. 1 It is probable that lichen ruber acuminatus and 
pityriasis rubra pilaris are one and the same disease. 

Lichen ruber, or lichen ruber acuminatus, is a chronic 
progressive disease of the skin marked by an eruption of 
small, red, conical papules tipped with a scale. These 
tend to run together and form lines, or diffused, red, scaly, 
infiltrated patches. 

Symptoms. The disease begins as a discrete eruption 
of millet-seed-sized, slightly scaly papules, that cause but 
little itching, and therefore are accompanied by but few 
excoriations. The papules may be bright or brownish 
red, conical, hard, covered with an adherent, dry, white 
scale, and imparting, when they are present in a sufficient 
number, a rough feeling to the touch. Or they may be 
pale red, waxy, smooth, rounded, and with a small angu- 
lar depression in their centre. The first outbreak may be 
scattered about the whole trunk and extremities, though 
somewhat more abundant on the flexor surfaces of the 
latter. Or it may be limited for a long time to a single 
region, such as the leg or genitals. After a time the 
eruption becomes general by the appearance of new pap- 

1 Lebrbucb der Hautkrankbeiten, 1872. 



LICHEN RUBER ACUMINATUS. 415 

ules either at the periphery of the first patch, or between 
the original papules, or irregularly over all. The single 
papules never increase in size during their whole course. 
After a time the papules crowd together, and melt into 
each other and form continuous, red, infiltrated patches of 
various sizes and shapes, whose surfaces are like shagreen 
leather or covered with scales. 

This is the most common course. Sometimes, however, 
the new papules appear in manifold circular rows about 
the older ones. The older ones sink in, disappear, and 
leave a darkly pigmented depression. The patches thus 
formed are usually on the extremities. 

In a fully developed case the skin is everywhere red- 
dened, scaly, and thickened, and the movements of the 
joints are greatly interfered with, so that they are held in 
a semi-flexed position. The thickening of the skin is 
specially marked on the palms, soles, fingers, and toes, 
and here rhagades are prone to form. The nails are 
thickened, uneven, brittle, broken, opaque, yellowish- 
brown ; or they are represented only by thin horny plates. 
The coarse hair of the head, axillae, and pubes is unaf- 
fected. Kaposi, in the third edition of his book, says 
that a defluvium capillorum takes place. 

The subjective symptoms are itching and a gradual pro- 
gressive interference with nutrition. At first the patient 
may feel quite well, but when the whole body is affected 
he falls into a general marasmus, and at last dies from 
the effects of the disease. 

So far Hebra. Subsequent observers have reported 
the occurrence of a bullous eruption in the course of the 
disease. 

Etiology. The cause of the disease is obscure. It 
affects all ages and conditions, but is most frequent in the 
male sex — about two-thirds of the cases. By many the 
disease is considered to be a neurosis. 

Diagnosis. It must be differentiated from psori- 
asis, eczema, pityriasis rubra, pityriasis rubra pilaris, 
and lichen planus. From psoriasis it differs, when in 



416 DISEASES OF THE SKIN. 

the early stages, iu that its papules do not enlarge into 
the large, characteristic psoriatic papules and patches ; in 
the later stages there are less scaling than in psoriasis uni- 
versalis, and more thickening of the skin ; and the palms 
and soles are far more profoundly diseased. From eczema 
it differs in that its papules neither undergo involution 
nor change into vesicles. Moreover, it does not itch so 
much, and there is never any moisture. From pityriasis 
rubra it differs in the greater thickening of the skin, and 
in its scaling, which is not in the form of thin plates or 
furfuraceous desquamation. From pityriasis rubra pilaris 
it is said to differ in being less scaly, in affecting the flexor 
surfaces by preference, in the darker color of the eruption 
from the first, in being more itchy, and in the profound 
constitutional disturbance. Nevertheless the opinion is 
gaining ground that the two diseases are identical. From 
lichen planus it differs in that it does not have its favorite 
locations upon the flexor surface of the wrist and inside 
of the knees, in having conical and not flattened papules, 
in not forming lilac-colored angular patches, and in a 
more frequent general involvement of the skin. 

Treatment. Arsenic, by the mouth or hypodermi- 
cally, is the drug upon which most reliance is placed 
for the cure of this disease. The drug must be pushed 
up to the limit of toleration, and given continuously 
for a long time, and for some weeks after the disappear- 
ance of the eruption. The hypodermic method is very 
painful. 

The external treatment is by means of tar, if not 
too irritating ; or we may simply address ourselves to 
the relief of the itching by means of carbolic acid, 1 or 
2 drachms to the pint of olive oil or pound of vaseline. 
Crocker speaks well of thymol or naphtol, gr. x to 5ij to 
the ounce of vaseline. Unna's * treatment has proved ser- 
viceable in many hands. He keeps the patient in bed 
between woollen blankets, and has him rubbed every 
morning and night with the following : 

1 Monatshefte f. prakt. Dermat., 1892, i., 5. 



LICHEN SCROFULOSORUM. 417 



R Hydrarg bichlor. gr. ii.-iv; 0.5-1 

Ac. carbolici, Biv; 2o 

Ungt. zinci oxid. benzoat, Jiv; 500| 



M. 



For the ointment of oxide of zinc, diachylon ointment 
may be substituted ; or a mixture of oil, lime water, and 
white bole may be used instead. Where the corneous 
layer is very thick, 2J drachms of chalk may be substi- 
tuted for the bole. 

Prognosis. The course of the disease is essentially 
chronic. Even when a cure is effected, relapses are liable 
to occur. Hebra at first said that all cases were fatal, 
but the use of arsenic and increased experience in the 
treatment of the disease have greatly modified his gloomy 
prognosis. 

Lichen Scrofulosorum or Scrofulosus. A disease of the 
skin occurring in strumous subjects, consisting in an erup- 
tion of small pale papules that tend to group in round or 
half-moon-shaped figures upon the abdomen, sides of the 
chest, and flanks. It is one of the so-called tuberculides. 

Symptoms. It occurs in the form of pin-point- to 
pin-head-sized, grouped, conical papules, which may be 
of the color of the skin, or pale red or fawn colored. 
These papules occur around the hair follicles and form 
small round groups, or circles or segments of circles, upon 
the abdomen, sides of the chest, flanks, and necks in 
adults ; and upon the extremities in children. They are 
somewhat scaly, but give rise to no inconvenience, so 
that they are often overlooked. In some cases the pap- 
ules are so numerous that the groups lose their distinctive 
shape, and large surfaces are covered, giving the skin a 
dirty-brown color. Many disseminated and discrete pap- 
ules are scattered over the body outside of the patches. 
Acne pustules may form ; and a brown pigmentation of 
the face has been observed in some cases. The papules 
finally undergo absorption, desquamate, and leave trans- 
itory yellowish pigmentation. The disease runs a chronic, 
slow course. Eczema may complicate matters. Kera- 
tosis pilaris is frequently well marked upon the limbs. 
27 



418 DISEASES OF THE SKIN. 

Etiology. The great majority of the subjects of this 
disease present evidences of scrofula. A few are robust. 
Some are phthisical, especially the children. The disease 
is most common in childhood, and is very uncommon 
after the twenty-fifth year of life. It is thought by 
many authorities to be a tubercular disease, due to the 
toxins of tuberculosis. Tubercle bacilli are not found in 
the papules. 

Pathology. The papule is composed of lymphoid, 
epithelioid and giant cells, infiltrating the papillae about 
the follicular opening, or the tissue about the vessels, hair 
follicles and sebaceous glands. Semiglobular masses in 
the horny layer of the epidermis, and around the hair fol- 
licles, have been described. 1 

Diagnosis. The disease must be differentiated from 
papular eczema, the papular syphilide, lichen ruber, a 
punctate psoriasis, and keratosis pilaris. Eczema differs 
from it in greater itching, in the brightness and rapid 
development of the papules, and in its tendency to vesi- 
culation or moisture. The papular syphilide is of darker 
red color, much larger, and more polymorphous ; the 
patient's age is usually greater, and the history and course 
of the eruption will soon decide the diagnosis. IAchen 
ruber has darker papules, which do not group in circles 
and segments of circles ; they itch, and tend to involve 
the whole surface. The patients are more often adults, 
and there is a profound constitutional disturbance. Pso- 
riasis itches, is abundantly scaly, and its papules soon 
enlarge and form characteristic patches. Keratosis pila- 
ris affects the extensor surfaces of the limbs by prefer- 
ence, each papule is plainly about a hair, and the papules 
do not group. A curled-up hair will often be found in 
the centre of the papule. The absence of spines in the 
papules distinguishes it from Crocker's lichen pilaris. 

Treatment. The persistent use of cod-liver oil both 
internally and externally will cure the disease. The 
syrup of the iodide of iron or the iodide of starch may be 
1 Gilchrist. Johns Hopkins Hosp. Bull., 1899, page 84. 



LUPUS ERYTHEMATOSUS. 419 

given with the oil. Good hygiene and food are valuable 
adjuncts. For the cod-liver oil, which is disagreeable 
for external use, other oil, such as cocoa-butter, may be 
used ; or vaseline with or without oil of cade. Crocker 
recommends the addition of liq. plumb, subacetatis, TTlxv, 
or thymol, 5 grains to the ounce of vaseline. The dis- 
ease tends to get well of itself. 

Lichen Simplex. See Papular eczema. 
Lichen Spinulosus. See Lichen pilaris. 
Lichen Tropicus. See Miliaria. 
Lichen Urticatus. See Urticaria. 
Lichen Variegatus. See Parakeratosis variegata. 
Linese Albicantes. See Atrophoderma. 
Linsenflecken. See Lentigo. 

Liodermia Essentialis. See Atrophoderma pigmento- 
sum. 

Lipoma is a fatty tumor. 

Liver Spot. See Chloasma. 

Lombardian Leprosy. See Pellagra. 

Lousiness. See Pediculosis. 

Lues. See Syphilis. 

Lumpy Jaw. See Actinomycosis. 

Lupoid Acne. See Acne frontalis and Lupus miliaris. 

Lupus Erythemateux disseminee. See Folliclis. 

Lupus Erythematosus. Synonyms : Seborrhoea conges- 
tiva ; Lupus superficialis ; Lupus sebaceus ; Lupus ery- 
thematodes ; Scrofulide erythemateuse, or Erytheme cen- 
trifuge (Fr.) ; Dermatitis glandularis erythematosa (Mori- 
son) ; Ulerythema (Unna). 

This is a chronic disease of the skin, occurring in vari- 
ously sized, slightly elevated, scaly, red patches which 
show a strong tendency to the production of atrophic scars. 

Symptoms. There are two varieties commonly de- 
scribed, namely, the circumscribed or discoid, and the dif- 
fuse, or disseminated, or aggregated. To these some of 
the English writers add a third, the telangiectic. 

The circumscribed or discoid form is the one most often 



420 



DISEASES OF THE SKIN. 



met with. It occurs generally on the face, specially upon 
the sides of the nose and the cheeks, the scalp, and the 
ears ; more rarely upon the hands and feet ; and still more 
rarely on other parts of the body. It begins by the ap- 
pearance of several isolated or grouped red spots slightly 
elevated, of pinhead to split-pea size, with a thin adherent 



Fig. 56. 




Lupus erythematosus (By the courtesy of Dr. S. Dana Hubbard). 

scale upon them. Some of these spots may be depressed 
in the centre. When the scale is removed there will be 
found upon its under side a delicate projection formed by 
a plug of sebaceous matter that dipped down into the 
mouth of the sebaceous gland. The mouth of the gland 
will be found patulous. These spots increase in size by 



LUPUS ERYTHEMATOSUS. 421 

peripheral extension to form disc-shaped figures of varying 
size ; neighboring ones will coalesce, and thus patches will 
be formed, also covered with the fine grayish or white ad- 
herent scales. Now when the scale is raised a number of 
the characteristic prolongations will be found on its lower 
side. The margins of the patches are slightly raised, but 
the middle parts undergo involution, are lower than the 
margins, and after a time are apt to become cicatricial, the 
skin being atrophied. The scar-tissue thus formed is thin 
delicate, and white, never puckered or deforming. 

The color of the patches is red, but of a peculiar hue 
that is characteristic, and perhaps can be best defined as 
violaceous. There is never any moisture connected with 
the disease. Burning or itching may or may not be pres- 
ent. The patches are of indefinite duration — months or 
years. At times they disappear of themselves, and do not 
leave scars, but the rule is that scars are left. The extent 
of the disease varies greatly, as well as the shape of the 
patches. The greater part of the face may be involved, 
or there may be only a single patch. Usually the eruption 
is symmetrical. A characteristic location for the disease 
is upon the back and sides of the nose and the contiguous 
parts of the cheeks, forming what has been fancifully called 
a butterfly, the ridge of the nose representing the back of 
the insect, and the cheeks its wings. Sometimes gyrate 
figures are formed. If the lobes of the ears are affected 
they may at first resemble erythema pernio, but later be- 
come shrunken. When the fingers and toes are affected 
they present the appearance of chilblains, a persistent ery- 
thema; but when involution takes place there is left an 
atrophic condition. It may also appear on the hands 
and feet in the same way that it does on the face. The 
mucous membranes and the vermilion border of the lips 
may be affected, presenting patches with punctate excor- 
iations of red color, or spotted with grayish masses of exu- 
dation and superficial cicatrices. The lips sometimes 
appear as if painted with collodion that is peeling off. 
Occurring upon the scalp it leads to permanent loss of hair 



422 DISEASES OF THE SKIN. 

from well-defined patches, and the same may be said 
of it as it occurs on other hairy parts. The affected 
areas are not only bald, but converted into thin cicatricial 
tissue, at first red, later white. The disease may become 
stationary after a time. Relapses are liable to occur. The 
general health is unaffected. 

The diffuse or disseminate form is a more acute process, 
and exceedingly rare in this country. The disease usually 
begins on the face, and the limbs are involved before the 
trunk. It may follow the ordinary form of the disease, 
or appear suddenly, or slowly develop. The patches are 
from pinhead to finger-nail size, slightly elevated, reddish 
brown, hypersemic, and hard ; they pale under pressure, 
and are attended with heat and burning. In this stage 
they resemble erythema exudativum or the papular 
stage of eczema. There may be from twenty to a hundred 
or more of them crowded together upon the face and scat- 
tered over the body. Many of them may disappear in a 
few days without leaving any trace, while others will 
remain and become characteristic patches of lupus erythe- 
matosus with depressed cicatrices. The individual lesions 
do not increase in size, and the patches are formed by 
aggregations of single lesions. The eruption may be ac- 
companied by a high degree of inflammation, exudation, 
and crusting, or even by bullae. There may be deep, pain- 
ful subcutaneous tumors in the joints and glands at first, 
over which characteristic patches will form. In some 
acute cases the development of the patches is accompanied 
by fever, osteocopic pains, and nocturnal headaches, and 
in some cases the patient will pass into a typhoid condi- 
tion and die of some lung complication. Or there may 
be a persistent inflammation of the face, erysipelas per- 
stans, which may lead through a typhoid state to death. 
There may also be swelling of the parotid glands and 
of various lymphatic glands. In some cases the disease 
bears a close resemblance to chilblain. 

The telangie die form occurs, according to Crocker, as a 
persistent circumscribed redness, which close inspection 



LUPUS ERYTHEMATOSUS. 423 

shows to be clue to dilated vessels, and is coinnionly lo- 
cated symmetrically upon the cheeks. Upon pinching 
up the skin it will be found to be markedly thickened. 
Some few comedones may be present. There is no des- 
quamation. It runs a chronic course. 

Crocker also describes a nodular form in which round 
or oval, convex, distinctly raised nodules appear, which 
are brownish red in color. They vary in size from a 
hemp seed to a small bean. They occur upon the face 
most often, but may occur elsewhere. They may undergo 
involution. 

Etiology. About two-thirds of the cases occur in 
women. It seldom occurs before puberty, and most of 
the cases are under thirty years of age, though Kaposi 
has seen a case in a child of three years. Beyond these 
facts we know but little of its etiology. The French 
regard it as a scrofulous affection which, in the light of 
modern pathology, is regarded as tubercular. While 
nothing suggesting its relation to a tuberculous process 
has ever been found in the skin, still, as not a few patients 
show other symptoms of a general tuberculosis, such as 
swollen or broken-down glands in the neck or cicatrices 
from the same, or give a history of tuberculosis in other 
members of their family, there is a growing opinion that 
the disease is a species of tuberculosis of the skin due to 
the toxins of that disease. The disseminated form is 
more often related to tuberculosis than is the discoid form. 
Crocker suggests a feeble circulation and prolonged expo- 
sure to great cold or heat as possible causes. It has been 
seen to follow upon frost-bite and sunburn. It would 
also seem that those who are subjects of seborrhcea are 
predisposed to the disease. 

Pathology. In spite of much careful study the ex- 
act pathology of the disease is still undetermined. J, A. 
Fordyce and O. H. Holder l believe that the process is due 
to embolism of the small arteries, arising either on account 
of an alteration in the blood due to a toxin, or to some 
i Med. Rec, 1900, lviii., 41, 



424 DISEASES OF THE SKIN. 

change in the walls of the vessels, or to a thrombus 
brought from some distant part. In the majority of cases 
the earliest manifestations of the disease are capillary ob- 
struction and then an infiltration of round cells in the 
middle of the lower zone of the corium, the sebaceous 
glands and hair follicles being secondarily involved. The 
cicatricial scarring is the result of atrophic processes. 
Robinson 1 regards the disease as a local infectious pro- 
cess, a granuloma, inflammatory in character. This view 
is held also by Schoonheid. 2 

Diagnosis. The disease must be differentiated from 
lupus vulgaris, eczema, rosacea, psoriasis, and syphilis. 
A typical case occurring upon the face in the form of red 
patches, with fine cicatrices in the centre, and covered 
with a delicate white or grayish adherent scale, from the 
under side of which are a number of projections, offers no 
difficulty in diagnosis. Lupus vulgaris differs from lupus 
erythematosus in occurring before puberty, in showing 
no disposition to symmetry, in the presence of apple-jelly 
tubercles, in being a deep-seated disease, and in leading 
to far more disfiguring cicatrices. Eczema never leaves 
scars, is prone to exudation, itches, its scales do not show 
prolongations from the under side, and its patches un- 
dergo more rapid and varied changes. Psoriasis will be 
pretty sure to show characteristic patches covered with 
thick scales, and never causes scarring or leads to per- 
manent loss of hair. Rosacea is largely composed of 
dilated bloodvessels, occupies the middle third of the 
face, often presents superficial pustules, does not leave 
scars, and is subject to frequent exacerbations. In syphi- 
lis a history of other lesions will be obtainable, there will 
be more evident infiltration, and the course of the lesions 
will be more rapid. The disseminate form of the disease 
is very difficult of diagnosis at first, but as soon as char- 
acteristic patches form the difficulty is removed. 

When lupus erythematosus occurs upon the scalp it 

1 Trans. Amer. Dermat. Assoc, 1898, p. 70. 
s Arch. f. Dermat. u. Syph., 1900, liv., 163. 



LUPUS ERYTHEMATOSUS. 425 

causes a bald spot that may be mistaken for alopecia 
areata, but differs from it in its irregular shape, in the 
signs of inflammation in it, and in the cicatricial condi- 
tion of the scalp it leaves. A microscopical examination 
of the hairs from about a patch will decide as between 
lupus erythematosus and favus or ringworm. 

Treatment. Little beyond the care of the general 
condition of the patient upon general principles can be 
done for lupus erythematosus in the way of internal medi- 
cation. McCall Anderson advocates the use of iodide of 
starch, made by triturating 24 grains of iodine with a 
little water, and gradually adding 1 ounce of starch, 
rubbing them well together until the mass becomes deep 
blue in color. Of this a heaped teaspoonful, increased 
gradually, may be given three times a day in water or 
gruel. Iodide of potassium is also commended, as are 
phosphorus and salicylate of soda. Crocker speaks well 
of salicin in 15-grain doses three times a day, increased 
to 20 or 30 grains. It is specially useful in acute cases. 
Whitehouse x has had good results from iodoform, 1 grain, 
t.i.d., after meals. Quinine seems to exert an influence 
on the disease when the patient can tolerate large doses. 
Hallander commends it in combination with painting the 
patch with tincture of iodine after washing it with abso- 
lute alcohol followed by ether. His dose is 7J grains of 
quinine from two to eight times a day, the number of doses 
being gradually increased. When the patch begins to fade 
the number of doses is to be gradually reduced. Few 
can carry such amounts. If cinchonism develops the drug 
is to be stopped until it subsides, and then begun again. 

Local Treatment. Sometimes in the early stages 
alkaline washes, such as lotions of zinc or lead, may be 
used. Or one composed of 

R 



M. 



Zinci sulphat., 


} 






Potassii sulphurat., 


aa 5j; 


aa4 


Alcohol, 




^iij; 


12 


Aquae rosse, 




adgiv; 


ad 128 



N. Y. Med. Jour., 1899, lxix., 159. 



426 DISEASES OF THE SKIN. 

as in acne and rosacea. Green soap or prepared olive 
soap, or its tincture, may be used in more chronic cases. 
This is often serviceable for the disease as it attacks tne 
eyelids. The affected parts are to be well rubbed with it, 
using a piece of flannel. The process is to be repeated 
every few days. If the reaction is too great, a little oil 
or a glycerin lotion may be applied. Crocker advocates 
the addition of 1 or 2 drachms of the oil of cade to the 
ounce of the tincture of green soap. Carbolic acid, 
pure, applied to the patches, often acts admirably. It 
turns them white at first. Caution is necessary at first, 
only a small patch being painted with it. If used on a 
large patch it may cause the patient to faint. The ap- 
plication is to be repeated as soon as the crust falls. 
Fowler's solution 5j in distilled water Sj, and spirits of 
chloroform 2 drops, applied externally in the morning 
and evening, is sometimes efficacious. Resorcin, 50 per 
cent, aqueous solution, applied once or twice a day until 
decided reaction takes place, and then cold cream or cal- 
amine lotion used until the reaction subsides, is a good 
plan of treatment. The resorcin solution must be re- 
peated when the reaction has subsided. Pyrogallol, 10 
per cent, in ointment, sometimes does well. N. Walker 
thinks that oxidized pyrogallol, 1 to 2 per cent, in 
acetone collodion, is the best means we have ; while 
others consider a combination of 10 per cent, pyrogallol 
with 40 per cent, of salicylic acid in collodion is bet- 
ter than anything else. Hydrochlor acetic acid, in full 
strength so as to whiten the skin ; oil of cade ; solution 
of naphtol, 1 per cent. ; tincture of iodine or iodide of 
glycerin ; caustic potash, 1 part to 6 or 1 2 of water, have 
their advocates. Hydronaphtol plaster, resorcin plaster 
of 10 to 20 per cent, strength, and mercurial plaster are 
often excellent when persisted in. Sulphur or ichthyol 
in ointment or paste does well in some cases. Tliilanin 
sometimes does well. H. Hebra has introduced the 
method of sopping the patches every fifteen minutes with 
pure alcohol containing 4 per cent, of menthol. Liquid 



LUPUS ERYTHEMATOSUS. 427 

air, or the snow from carbon dioxide, act like caustics in 
these cases and sometimes gives most brilliant results. 
The part is frozen with it for a few moments. Both the 
Einsen light and x-rays have cured many cases. The 
former gives the best results — though they are attained 
slowly — and does not make the disease worse. It is not 
so useful in the chronic, thickened, deep-seated patches as 
in the more superficial form. In some cases arrays ag- 
gravate the disease. Pusey recommends exposures of 
weak intensity. At present we have no better agents for 
cure than these two. The high-frequency current, ap- 
plied by means of vacuum glass tubes or a carbon point 
from three to ten minutes, has cured some superficial cases. 
The tube should be held a short distance from the skin 
so as to cause a bombardment of it by the sparks, and the 
strength of the current used snould be such as to be short 
of causing severe pain. All cases should be carefully 
watched that the reaction from our remedies does not go 
too far. If the remedy produces too much reaction, it 
must be stopped, a mild zinc lotion applied until the 
irritation subsides, and then the remedy is to be used 
again. 

If these superficial caustics do not cure, resort may be 
had to linear scarifications, making a series of cross-hatch- 
ings, taking care not to go very deep. The bleeding is 
to be checked by pressure and the application of carbolic 
acid, 2 drachms to the ounce. Limited surfaces must 
be taken at a time. Electrolysis by means of multiple 
punctures will sometimes give brilliant results. Some- 
times running the needle across the patch, making a num- 
ber of parallel insertions, will have a good eifect. Erosion 
with a curette, galvano- or Paquelin cautery and strong 
escharotics, such as the acid nitrate of mercury, may have 
to be used in very obstinate cases, but not till all other 
means are exhausted, as they are apt to leave deep scars. 

Prognosis. The prognosis should be guarded, as the 
disease is a most obstinate one, and prone to relapses. 
Though it may persist for many years there is a tendency 



428 DISEASES OF THE SKIN. 

to recovery as the disease is seldom seen in old people. A 
cure may, however, be effected by patient perseverance. 
It is wise always to tell our patients that scars are liable 
to be left, not only by the treatment employed, but by the 
disease itself. An accidental attack of facial erysipelas 
cured one case under my observation. Epithelioma may 
develop on the cicatrix of a patch. The discoid form has 
little effect upon the health of the patient, but the dis- 
seminated variety not infrequently ends fatally. 

Lupus Exedens. See Lupus vulgaris. This term is 
sometimes applied by surgeons to epithelioma. 

Lupus Exfoliativus, seu Exulcerans, seu Hypertrophicus. 
See Lupus vulgaris. 

Lupus Follicularis. Probably the same as Acne necro- 
tica, which see. 

Lupus Miliaris or Lupoid or Adenoid Acne. See Acne 
necrotica and lupus vulgaris. 

Lupus Pernio. This disease affects the uncovered parts, 
hands, face, and specially the ears, nose, and upper lip. 
It is ill-defined, and extends over large surfaces. It is 
marked by cyanosis, telangiectasis, infiltration of the skin, 
diffuse tumefaction, Assuring of the skin, and superficial 
vesiculation. Slight ulcerations form that become cov- 
ered with crusts and last a long time. The old patches 
are studded with irregular cicatrices. It is a chronic dis- 
ease with no subjective symptoms. It occurs in lym- 
phatic subjects, and is distinct from the other varieties of 
lupus. 1 

Lupus Sebaceus, seu Superficialis. See Lupus erythe- 
matosus. 

Lupus Tuberculosus, seu Verrucosus, seu Vorax. See 
Lupus, vulgaris. 

Lupus Vulgaris. Synonyms : Besides those given above, 
which merely describe certain stages or forms of the dis- 
ease, and are quite unnecessary to be remembered, we 

i Tenneson : Atlas de Musee de 1' Hdpital St. Louis, p. 135. 



LUPUS VULGARIS. 429 

have : Noli me tangere ; Herpes esthiomenes ; (Fr.) Dartre 
rongeante, Scrofulide tuberculeuse, Esthiomene; (Ger.) 
Fressende Flechte. 

This is a chronic neoplastic disease of the skin due to 
its invasion by the tubercle bacillus, and characterized by 
one or more brownish-red papules, tubercles, or infiltrated 
patches, that tend either to absorption or ulceration, and 
always leave scars. 

Symptoms. Lupus vulgaris usually begins in child- 
hood and upon the face ; the cheek and nose being the 
parts most usually affected. The initial lesion is a dark- 
red or brown pin-point- to pinhead-sized papule, which 
may be on a level with the skin, depressed below, or 
raised above it. It is a tubercle in an anatomical sense. 
When it is punctured by a pointed instrument it is felt to 
be soft, readily being entered. There may be but a single 
lesion, but usually there are a few of them either grouped 
or scattered. After a time slightly scaly patches will form 
by the coalescence of the lesions which have enlarged into 
brownish-red, semi-translucent, smooth, shiny tubercles, 
or by the development of new lesions between the old ones. 
The shape of the patches is irregular. Rarely are they 
ring-shaped. The size of the patches varies greatly, but 
they are always elevated above the surface of the skin, of 
a dark-red color, and studded with the little brownish-red 
papules, so-called tubercles. The appearance of these 
tubercles has been likened by Hutchinson to that of apple- 
jelly. About the patch there may spring up new tuber- 
cles in the sound skin. There may be but one patch, or 
the whole face may be more or less covered with a num- 
ber of them. Symmetry is not a feature of the disease, 
often only one side of the face being affected. Sometimes 
two or more patches will coalesce at their borders, their 
centres will fade out, or rather become atrophic, and a 
gyrate patch will form, creeping over the skin with a 
well-marked, elevated, dark-red border. The centre of 
all the patches is lower than the border, and eventually 
is atrophic. 



430 DISEASES OF THE SKIN. 

The course of the disease is slow and chronic, and 
the fate of the patches varies greatly. For months 
or years they may remain absolutely quiet, and then 
show signs of activity by new lesions appearing about 
the edges of the patches or in the scar-tissues. This 
recrudescence in the scar is a characteristic of the 
disease. The patches may entirely disappear, leaving a 
fine smooth cicatrix ; this is rare without treatment. Or 
they may break down and form ulcers, which are irreg- 
ularly rounded, shallow, with easily bleeding floors, and 
a moderate amount of purulent secretion that dries into a 
crust. This is the so-called lupus exulcerans, and is not 
very frequent in this country according to my experience. 
Sometimes upon this ulcerated surface papillary or warty 
growths will spring up, the so-called lupus papillomatosus 
or verrucosus. Sometimes the infiltration of the patch is 
unusually great, and then we have lupus hypertrophieus. 
Most commonly we have a non-ulcerated, exceedingly 
chronic infiltrated patch with areas of cicatricial tissue 
scattered through it. When the disease attacks the end 
of the nose, the whole of the soft parts is involved, and it 
will cause it to shrink up and convert it into cicatricial 
tissue. When the ear is diseased, it also shrinks up so as 
to be half the size it was originally. These changes are 
due either to ulceration or to the gradual absorption of 
the lupus tubercles. 

While the face is the site of predilection of lupus, it 
may also occur upon any part of the skin of the body, as 
well as upon the mucous membranes. In this latter situ- 
ation it is most often secondary to the disease elsewhere ; 
still it is often primary. Thus Bender x found that 30 T \ 
per cent, of all his lupus cases began in the nasal mucous 
membrane. Pontoppidan also found the origin of the 
disease to be the nasal mucous membrane in many cases. 
In the nose it frequently leads to perforation of the sep- 
tum, and sometimes causes great deformity of the nose, 
but it does not attack the bones. All other mucous mem- 
1 Vierteljahr. f. Derm. u. Syph., 1888, xv., 891. 



LUPUS VULGARIS. 431 

braiies may be attacked, the rectum and vagina being 
least often affected. Upon mucous membranes we do not 
see the same tubercles as on the skin, but papillary ex- 
crescences which form patches. They may be absorbed or 
ulcerate. The conjunctivae may be involved primarily 
or secondarily. Epithelial cancer has developed in very 
rare instances upon the lupoid tissue itself, more com- 
monly upon the scar tissue left by the lupus. Whenever 
it develops as a sequela of lupus its course is more rapid 
and its prognosis far more grave than is usually the case. 
Erysipelas is a not infrequent complication of lupus, and 
is sometimes curative in its action. Lupus of the extrem- 
ities is often followed by permanent deformities and dis- 
abilities, and sometimes by tubercular lymphangitis. 
Implications of the lymphatic glands is exceptional in 
lupus, and then only in advanced cases. 

Under the names of lupus follicularis disseminatus and 
lupus miliar is have been described unusual cases of tuber- 
culosis of the skin that are seen mostly in young people 
in a rather acute form, reaching their full development in 
a few weeks or months. It affects specially the forehead 
and cheeks, upper extremities and back. The eruption 
consists in large and small tumors infiltrating the whole 
thickness of the skin. On a number of them are seen 
miliary brownish nodules partly in groups, partly dis- 
seminated. These nodules also sometimes occur in the 
skin apart from the tumors. The lesions are isolated as a 
rule, but may become confluent in patches. It is thought 
that they are due to emboli coming from some internal 
tubercular deposit. 

Etiology. Lupus has long been regarded as a man- 
ifestation of scrofula. It is now demonstrated that it is a 
tubercular disease. It should be placed under the title 
of Tuberculosis cutis, but usage makes it advisable to con- 
sider it by itself. Many patients with lupus are plainly 
strumous; many, 55 T 9 ¥ per cent, of Sach's 1 cases, are 
either tuberculous themselves or have a decided history 
1 Vierteljahr. f. Derm. u. Syph., 1888, xiii., 241. 



432 DISEASES OF THE SKIN. 

of the occurrence of phthisis in their family. The phthis- 
ical history is far less pronounced in this country than it 
is in Europe. It is no uncommon thing for several mem- 
bers of the same family to have lupus. It is probable 
that we could find a close connection between lupus and 
infection with the tuberculous virus in all cases, were it 
practicable to do so. It has been noted frequently to 
follow piercing of the ears, and circumcision accord- 
ing to the Jewish rites, and, at times, vaccination. Ex- 
ceptionally the infection of the skin may take place by 
way of the lymphatics or bloodvessels from a tubercular 
focus more or less distant. Another evidence of its tuber- 
cular origin is found in the nearly uniform reaction of 
lupus to tuberculin. It is much more frequent in females 
than in males, about 62 percent, being in females accord- 
ing to Block's and Sach's statistics. It begins in more 
than half the cases before the fifteenth year. It may be- 
gin as early as the second year. It is almost always a 
disease of youth. 

Pathology. The pathology of lupus has been studied 
by many competent investigators. " It is a neoplasm of 
the granuloma class, and consists of a small-cell infiltra- 
tion which begins in the deep part of the corium, and from 
thence gradually invades all the other skin structures," 
says Crocker. Giant cells are more uumerous than usu- 
ally observed in tuberculous tissue, and there is greater 
formation of vascular connective tissue. In the older 
nodules the tuberculous elements necrose and maybe ab- 
sorbed and replaced by connective tissue, or break through 
the thinned epidermis with consequent ulceration and sec- 
ondary septic infection. The tubercle bacillus is found 
in the tissues, though but sparsely. Inoculations of ani- 
mals have not always been successful, but in a goodly num- 
ber of cases the inoculations have been followed by general 
tuberculosis, so as to warrant our belief in the tubercular 
nature of the disease. It has been suggested that as the 
bacilli are present in but a small number, the irritation 
of the tissues is due to the toxins produced by them. 



LUPUS VULGARIS. 433 

Diagnosis. Lupus is most commonly confounded with 
a tubercular or gummous syphilide. It may have to be 
differentiated from a scrofuloderm originating in a caseous 
gland, from an epithelioma, lupus erythematosus, and 
possibly lepra. From syphilis it is diagnosticated by the 
presence of the characteristic apple-jelly tubercles ; by its 
slow course ; by its history ; by the absence of all other 
signs of syphilis ; by its little tendency to ulceration ; by 
the superficial character of its ulcers and their slight 
crusting ; and by its sparing the bones. If there is still 
any doubt, appeal may be made to the effect of treatment 
by means of the iodide of potassium and mercury, which 
will have no effect upon the lupus. As the scrofuloderm 
is another manifestation of the tubercular diathesis and 
amenable to the same treatment as that of lupus, its dif- 
ferentiation is not so important. It, however, will begin 
about a caseous and broken-down lymphatic gland or 
gumma, will probably have sinuses, and no characteristic 
tubercles. An epithelioma begins usually after the thirty- 
fifth year ; has no tubercles ; and forms a deep ulcer with 
raised, hard, waxy edges crossed with dilated bloodves- 
sels. The diagnosis from lupus erythematosus is given in 
the preceding section. Leprosy presents large tubercles 
which are anaesthetic, and this at once decides in its favor. 

Treatment. As lupus is a tubercular disease, and 
sometimes is followed by tuberculosis of the lungs, care 
must be given to the general health of the patient, and he 
must be placed in the best possible hygienic surroundings. 
His diet should be nutritious, and cod-liver oil, iodine, 
the hypophosphites and iron should be given. While 
these measures may not remove the lesions they place the 
patient iu a better condition to resist the spread of the 
disease. The thyroid extract has been used with some 
benefit. Buck 1 reports the cure of a case, of fourteen 
years' standing, by the administration of urea. He began 
by giving 20 grains three times a day and increased 
the dose gradually to 1 drachm. Tuberculin injections 
1 Practitioner, 1901, xiv., 140. 
28 



434 



DISEASES OF THE SKIN. 



using the new tuberculin (T. R.) according to the new 
method of using small doses of 1 to 2 milligrams and 
increasing the dose by 2 milligrams have done well in 
some cases. The injections should be followed by slight 
reaction and an increase to 1° F. in temperature. The 
injections may be repeated every two days. 

But local treatment is of the greatest importance, 
and the disease must be gotten rid of root and branch. 
If a single diseased cell remains, the disease is sure to 
return. To effect its destruction surgical procedures had 
best be resorted to. The whole patch or patches may be 
scraped out with the dermal curette, and this followed 
by a 25 or 30 per cent, pyrogallol ointment for a week 
or ten days, and that in turn by mercurial plaster for 
another equal term. The pyrogallol will cause free sup- 
puration and destroy the cells left behind by the curette. 
A second or third course may be necessary. Piffard 
prefers to touch the base left after curretting with the 
galvano-cautery at a red heat. The wound is then to 
be packed with absorbent cotton. After about ten to 
fourteen days the crust and cotton will fall off and leave 
a soft, smooth, pliable cicatrix. Multiple scarifications 
have proved of service. They may be made with 
a many-bladed instrument constructed for the purpose, 
or with a scalpel, or a knife shaped like a butcher's cleaver 
(Fig. 57.) They must go deep enough to penetrate all 

Fig. 57. 




Scarifying-knife. 
the softened tissue, but not to wound the sound parts. 
The resistance offered by the healthy tissue will be suffi- 
cient guide for this. The scarifications should be so made 
as to divide the tissues into little squares, thus : 



LUPUS VULGARIS. 435 

They may be repeated in five or six days, and need no 
after-treatment. This is VidaPs method. The individual 
tubercles may be bored out with Morris's double-screw 
instrument, or with dental burrs and hooks dipped in 
pure carbolic acid, as proposed by Dr. George H. Fox. 
This is an excellent method. The galvano- or Paquelin 
cautery may be employed to destroy this disease. This 
will require the administration of an anaesthetic, while 
the former procedures do not require it, or at most any- 
thing more than local anaesthesia by means of cocaine. 
Multiple punctures by means of the galvano- or thermo- 
cautery at somber red-heat at 1 millimeter distance for 
small patches and linear scarifications with cautery knife 
for large ones, followed by emplast. de Vigo, and repeated 
once a week, is Besnier's method. Electrolysis in mul- 
tiple punctures or by passing the needle through the patch 
or by means of a flat metallic button, is a useful mode 
of treatment. The current must measure 3 to 5 mil- 
liamperes, and it must be continued for five minutes, 
when the button is used. Lang 1 advocates excision of 
the patches when not too large, followed by grafting. He 
has operated in 85 cases, 58 of which he was able to fol- 
low up. Of these, 39 remained free from relapses. This 
method is to be preferred in small patches. 

These surgical procedures have largely superceded the 
use of caustics, though the latter are valuable and may 
be used when the patient fears an operation. Arsenic 
may be employed in the form of a paste, such as Hebra's 
modification of Cosme's paste : 

R Ac. arsenios, gr. x; 1 65 

Hydrarg. sulphureti rubri, £j ; 
Ungt. aq. rosae, ad 3J ; 3o| M. 

which is to be spread on lint or linen, applied evenly, 
and bound down firmly. It is to be left on for twenty- 
four hours, then removed and reapplied till ulceration is 
set up. It is painful. Vienna paste, of equal parts of 

1 Dermat. Zeitschrift., 1900, vii., 805. 



436 DISEASES OF THE SKIN. 

caustic potash and unslacked lime ; or a chloride of zinc 
paste may be used, such as 1 part of ziuc to three parts 
of starch. Both are painful. Many think highly of 
boring into the patch with the solid nitrate of silver stick. 
Salicylic acid, 20 to 25 per cent., in plaster or plaster- 
muslin, changed once or twice a day is good. It is well 
to combine creosote with the salicylic acid, 2 parts to 1, 
to allay the pain caused by the acid. The local appli- 
cation of bichloride of mercury in solution (gr. j to Sj) to 
ulcerated forms, and in ointment to non-ulcerated forms, 
is commended by White and others. 

Unna 1 recommends painting with pure carbolic acid 
for from two to four days. He has also had good results 
with a salve-muslin containing 1 per cent, of bichloride 
of mercury, 20 per cent, of carbolic acid, and 36 per 
cent, of oxide of zinc. He 2 has also recommended the 
following procedure : Little sticks of hard wood are 
sharpened and then soaked for several days in a solution of 

R 



Hydrarg. bichlor., 


gr. xv ; 


1 


Ac. salicylici, 


3iiss ; 


10 


iEtheris sulph., 


3vj; 


24 


01. olivae, 


ad 3iij ; 


ad 100 



M. 

A stick is forced into each tubercle, cut off close to the 
skin, and covered with gutta percha or carbolized mer- 
curial plaster. After two days the plaster is removed, 
leaving a surface covered with a thin layer of pus. The 
holes made by the sticks are enlarged and the sticks lie 
loose in them. The sticks are removed, the surface asep- 
tically cleansed, the holes filled with a powder of 

ft Hydrarg. bichlor., gr. iss; 01 

Magnes. carbonat., 3ii ss > 10 

Ac. salicylici, 5j g r - xv ; 5 

Cocain. muriat., gr. viiss; 5 M. 

which is blown on with a powder-blower and worked in 
by the fingers or with a wooden spatula. The patch is 
again covered with the plaster for twenty-four hours, 

i Monatsbefte f. prakt. Dermat., 1891, xii., 341. 
2 Ibid., 1895, xxi.,281. 



LUPUS VULGARIS. 437 

when the procedure is repeated for another day. The 
subsequent treatment is by pyrogallol. 

S. Reines x endorses Ehrmann's method which is to 
cover the part with a 33 J per cent, resorcin paste spread 
on linen and bound down. This is to be removed in 
twelve hours, and leaves the skin a grayish white color. 
This gray pellicle is to be curetted off, and the paste re- 
applied, and the treatment so continued for five or six 
days. For the next two or three days a boric acid oint- 
ment is to be used. Return is to be had to the resorcin 
and the method followed out till cured. Large patches 
must be treated in small sections at a time. After the 
first four or five days the arrays may be used. A. W. 
Williams 2 reports the cure of one case and great im- 
provement in others by painting the part with a 5 per 
cent, watery solution of eosin until the skin is stained a 
distinct pink color, followed by exposure of the part to 
the direct sunlight for one or two hours daily. 

The most recent treatments of lupus are by the Roent- 
gen rays, phototherapy, the high-frequency current, and 
radium. The first two methods require expensive ap- 
paratus, and radium is very costly. All are slow. Pho- 
totherapy is known as Finsen's method. Both sunlight 
and electric light are used concentrated by means of a 
focussing apparatus upon the patch rendered bloodless by 
pressure with a convex glass. Each sitting by sunlight 
lasts two hours, by electric light one hour. The treat- 
ment must be repeated daily. It does not act well in 
ulcerative cases and in old cases which have been oper- 
ated on and have a great deal of scar tissue. In suitable 
cases the cosmetic effects are very good. The results 
from x-rays are more rapidly obtained, are equally as 
good, and the rays can be used in all forms of lupus. 
They must be strong enough to cause erythema, but not a 
violent reaction, and a new exposure is to be made as 
soon as the reaction subsides, or in about two weeks. At 

i Berlin., Klin. Woch., 1905, xliii., 1161. 
2 Brit. Jour. Dermat., 1907. xix., 43. 



438 DISEASES OF THE SKIN. 

first the time of exposure to a medium tube should be 
five minutes and the distance from the target ten inches. 
Exposures should be given every three or four days ; 
after two weeks the distance may be decreased, and the 
time increased until the reaction we desire is obtained. 
Radium is still on trial and reports from observers vary 
as to results obtained. The high-frequency current is used 
with glass electrodes, or carbon point, holdiug the tube 
a short distance from the skin so as to spark it, and using 
a current as strong as the patient will bear with comfort. 
Prognosis. The prognosis should always be guarded. 
Relapses after any plan are too often seen. A scar must 
result both from the disease and its treatment. The pos- 
sibility of the development of a general tuberculosis must 
also be borne in mind, although many patients preserve 
throughout the course of the disease a robust state of 
health. 

Lymphangiectasis. Varices of the dermal lymphatics 
may be superficial or deep ; and affect the trunk, the 
meshes, or the lacunae, though most commonly all parts 
of the vessels are diseased. When they are superficial 
they form ampullary swellings at the surface of the skin 
which may be isolated or agglomerated. In size they 
vary from that of a millet-seed to that of a pea or larger. 
In color they vary with that of the skin. They break 
more or less easily and discharge lymphatic fluid. If 
deep, they can be more readily felt than seen, or form 
upon the surface of the skin isolated or associated raised 
cords which run a more or less tortuous course. After 
a time these also break and discharge lymph. 

Hallopeau and Goupil l describe under this title a dis- 
ease that they believe to be of tubercular origin, and that 
appears about a bony prominence of the extremities as a 
diffuse tumefaction or a cushion-like elevation resembling 
varicose vein tumors. They eventually open and dis- 
charge pure lymph or lymph mixed with pus. Fresh 

1 Ann. de derm, et de syph., 1890, i., 957. 



LYMPHANGIOMA, 439 

tumors arise iu the course of the lymphatics iu au ascend- 
ing series ; also gummy nodes. The affected limb is 
swollen, indurated, and of more or less somber red. The 
prognosis is grave, and the proper treatment undetermined. 

Lymphangioma, also called Lymphangiectasis, Lymphan- 
giectodes, Lupus Lymphaticus, and Lymphorrhagica Pachy- 
dermia, is a rare disease. It consists, according to Crocker, 
of a number of minute, deep-seated vesicles, closely 

Fig. 58. 




Lymphangioma. (Epstein.^) 

crowded together in irregularly outlined groups of 
from one-third to one-quarter of an inch in size. 
These groups are arranged irregularly with healthy skin 
between them, or a few scattered vesicles in the otherwise 
healthy skin. They are usually confined to a single 
small area. The vesicles are deep-seated with thick walls, 
some of them almost warty-looking. They are pin-point 
to hemp-seed size, colorless or straw-colored, or pinkish, 
and contain a clear fluid. Some have vascular striae or 
tufts over them, others red clots, others contain extra va- 
sated blood. They run a chronic, non-inflammatory 

1 By permission from Journ. Cutan. and Gen.-Urin. Dis., 1892, x., 
214. 



440 DISEASES OF THE SKIN. 

course, spreading slowly at the periphery, and tending to 
relapse if removed. Most of the few cases have occurred 
in males and begun in early childhood. 

The disease is of lymphatic origin, and the main feature 
is dilated lymphatic vessels. 

The treatment consists in destruction by caustics ex- 
cision, or electrolysis ; but relapses are liable to occur. 

Lymphangioma Tuberosum Multiplex. This is a still more 
rare disease than lymphangioma, and consisted, in Kaposi's 
case, in the appearance all over the trunk and neck of 
hundreds of lentil-sized, rounded, brownish-red, smooth, 
glistening, disseminated, flat or elevated tubercles. They 
were firm and elastic, slightly painful, and upon some of 
them were dilated bloodvessels. One or two other cases 
of the same kind have been reported by others. The dis- 
ease generally begins in childhood or early youth. By 
some this disease is regarded as a specimen of benign 
cystic epithelioma. 

Lymphoderma Perniciosa. See Mycosis fungoides. 
Lymphorrhagica Pachydermia. See Lymphangioma. 
Lymphosarcoma. See Sarcoma, 

Maculae et Striae Atrophicae. See Atrophoderma stria- 
tum et maculatum. 

Maculae Caeruleae. See Pediculosis vestimentorum. 

Madura Toot. See Fungous foot of India. 

Mai de la Rosa. See Pellagra. 

Maladie des Vagabonds. See Pediculosis. 

Malignant Papillary Dermatitis. See Paget' s disease. 

Malingering. See Dermatitis factitia. 

Malleus. See Equinia. 

Mamillaris Maligna. See Paget' s disease. 

Mask. See Chloasma. 

Measles. See Morbilli. 

Medicinal Eruptions. See Dermatitis medicamentosa. 

Melanoderma, seu Melasma. See Chloasma. 

Melastearrhee. See Chromidrosis. 

Melanosarcoma. See Sarcoma. 



MILIARIA. 441 

Melanosis Lenticularis Progressiva. See Atrophoderma 
pigmentosum. 

Melitagra. See Pustular eczema. 

Melung. According to H. Ziemann 1 This is a dis- 
ease that affects negroes on the West African coast. It 
begins between the tenth and fifteenth year of age, develops 
symmetrically, and affects only the hands and feet, stop- 
ping at the wrists or ankles. It takes the form of more 
or less round, oval, or irregular macules, which are red- 
dish-white with a tinge of yellow. When the disease is 
fully developed the hands and feet have an extraordinary 
marbled or piebald appearance. It seems to be heredi- 
tary, and to affect more boys than girls. It is probably 
a form of vitiligo. 

Mentagra. See Sycosis. 

Miliaria. Synonyms : Sudamina ; Lichen tropicus : 
(Ger.) Frieselausschlag ; Prickly heat. 

This is a disease of the sweat glands due to excessive 
sweating, which may or may not be inflammatory, and is 
characterized by an eruption of discrete papules, vesicles, 
or pustules. Several varieties are described, but it is 
enough to distinguish two forms, namely, sudamina* and 
lichen tropicus. 

Symptoms. Sudamina, also called miliaria crystallina, 
is the form that is met with during the course of febrile 
diseases, and occurs as an eruption of an immense num- 
ber of small, closely crowded, but discrete, bright, pearly 
vesicles entirely without inflammation or subjective symp- 
toms. They are most abundant on the trunk, especially 
upon its anterior plane, but may occur anywhere. After 
lasting a few hours or days they are absorbed and dis- 
appear by drying up, possibly with some scaling, or they 
may rupture and dry up. 

Lichen tropicus is very commonly seen in this country 
during warm weather. It may consist in an eruption of 

1 Archiv. f. Dermat. und Syph., 1905, lxxiv., 163. 



442 DISEASES OF THE SKIK 

pin-point, bright-red papules (miliaria papulosa) ; or ot 
very small vesicles upon an inflamed skin (miliaria rubra) ; 
or the eruption may be a composite one of papules inter- 
spersed with vesicles and pustules. Whichever form it 
may assume, the lesions are present in great number, and 
closely crowded together, though not aggregated. It may 
involve the whole surface of the body, but is most com- 
mon on covered parts, and especially upon the trunk. The 
eruption is apt to become better or worse according to 
the changes in the temperature of the atmosphere. The 
disease may last in this way throughout the warm weather. 
It is no uncommon thing for furuncles to form, and even 
cutaneous abscesses. Itching, pricking, and burning are 
always annoying accompaniments. If the skin is much 
scratched, eczema may complicate the disease. The old 
nurse's " red gum," the strophulus of older writers, is a 
miliaria. Kaposi regards the disease as an eczema. 

Etiology. The cause of sudamina is retained sweat, 
owing, probably, to epithelium clogging up the sweat 
pores when sweating is stopped on account of the fever. 
When the fever passes and the sweat glands resume their 
function the rush of sweat to the surface raises up the 
epithelium over the pores into little vesicles. They soon 
give way and the trouble is over. Lichen tropicus is due 
to congestion about the sweat pores and irritation of the 
skin when profuse sweating is induced by too warm cloth- 
ing and hot weather. It is also suggested that checkiDg 
a profuse sweat may cause it. It is seen most commonly 
in babies and fat people. It is noticeable in this city 
(New York) that the children who live near the river 
front and are a good deal in the salt water escape the 
disease, while it is very common in the rest of the tene- 
ment-house population. 

Diagnosis. Sudamina differs from vesicular eczema in 
its sudden occurrence during a febrile process ; in being 
non-inflammatory ; in its vesicles not breaking down 
readily and in not itching. Lichen tropicus differs from 
eczema in the minuteness of its papules ; its sudden ap- 



MILIUM. 443 

pearance ; not forming patches which are moist ; having 
a high atmospheric temperature as an evident etiologi- 
cal factor, and the tingling rather than the itching of the 
eruption. 

Treatment. Sudamina needs no treatment, as with 
the subsidence of the fever it gets well of itself. Lichen 
tropicus requires attention to the diet, cutting off the meat 
in children and lessening its amount in adults. Cooling 
drinks and the administration of gentle saline laxatives 
are also advisable. Locally, bathing in salt water or 
alkaline lotions, and subsequent powdering of the skin, 
conjoined with wearing light clothing, and not using 
too warm bedcovers, will relieve and ofttimes cure the 
trouble. 

Miliary Fever, or the sweating sickness, is an epidemic 
disease accompanied by profuse sweating and miliaria. 
The epidemics have occurred most often in France. 

Milium. Synonyms : Grutum ; Strophulus albidus ; 
Acne albida ; Tuberculum sebaceum. 

Symptoms. These are small pinhead- to split-pea- 
sized, firm, whitish or yellowish, slightly elevated papules 
that occur usually upon the face. They are spherical in 
shape, and slowly increase in size up to a certain point, 
when they remain stationary. When incised and pressed 
upon laterally a small, white, round, oval, or tabulated 
mass emerges. They give rise to no subjective symptom. 
While their most common site is the face below the eyes, 
they may occur anywhere on the face ; and also upon 
the border of the lips, the penis, and scrotum. In this 
latter situation they are more decidedly yellow in color, 
flat and often attain the size of a small bean. Along the 
corona glandis they are sometimes very thickly strewn. 
On the genitals of women their most frequent site is the 
labia minora. There may be but one or two, or a score of 
them. Occurring in the eyelids they are called chalazion. 
When they undergo calcareous degeneration (an infrequent 
occurrence) they form cutaneous calculi. Comedones are 



444 DISEASES OF THE SKIN. 

often present at the same time with milia. Any part of 
the body may be affected. 

Etiology. Milia occur chiefly in infants and young 
adults, and sometimes follow other diseases of the skin, 
such as pemphigus, erysipelas, or those in which destruc- 
tive processes have taken place and cicatrices formed. 
They are often congenital. 

Pathology. They are supposed to be due to retained 
secretion on account of the upper layers of the stratum 
corneum growing over the openings of the sebaceous 
glands, or to a non-development of the glands. Robinson 
thinks that some of them are due to " miscarried embry- 
onic epithelium from a hair follicle or from the rete," 
while those " following pemphigus, erysipelas, syphilis, 
and lupus consist of fatty epithelium and cholesterine, the 
epithelium being often arranged in concentric layers 
around a central flat nucleus." 

Diagnosis. They must be differentiated from xan- 
thoma. The latter are more of a lemon-yellow or buff 
color, and cannot be squeezed out when incised. Mollus- 
cum is sometimes mistaken for milium, but it is more 
prominent and hemispherical, and has a central punctum, 
out of which its contents can be squeezed without punct- 
uring its top. 

Treatment. The treatment cousists in pricking the 
top of the papule and pressing out its contents. To make 
sure of the destruction cf the growth a drop of carbolic 
acid or iodine may be introduced into the cavity remain- 
ing. Hardaway advocates electrolysis as being the 
speediest and best treatment. If operative procedures are 
inadmissable, the skin may be caused to exfoliate by the 
use of green soap, salicylic acid, or resorcin ointment, 
when the milia will be destroyed. 

Milk Crust. See Eczema. 
Mitesser. See Comedo. 
Mole. See Nsevus. 

Molluscum Cholesterique. See Xanthoma. 



MOLLUSCUM CONTAGIOSUM. 



445 



MoILuscum Contagiosum. Synonyms : Molluscum epi- 
theliale, sen sebaceum, seu sessile, seu verrucosum ; Epi- 
thelioma contagiosum ; (Fr.) Acne varioliforme, Ecder- 
moptosis. 

Symptoms. This is a contagious disease of the skin 
that occurs in most cases upon the face and in children, 
and is characterized by the appearance of one or more 
rounded pearly Avhite or pinkish discrete tumors, varying 




Molluscum contagiosum. (By the courtesy of Dr. S. D. Hubbard.) 

in size from that of a pinhead to that of a large pea. (Fig. 
59.) These tumors are waxy or opaque, and on top are 
slightly flattened, and show an umbilication or small 
depression, out of which the soft cheesy contents of the 
tumors can be squeezed. They are at first very small, 
but gradually grow until they attain a certain size, when 
they may remain unchanged for an indefinite period ; or 
they may become inflamed, break down of themselves, 
discharge their contents, and disappear either without 
leaving any trace or with a very slight scar. Not 



446 



DISEASES OF THE SKIN. 



infrequently scores of these tumors are found on the 
same subject. They are commonly sessile, but may 
become more or less pedunculated. The genitalia, breast, 
and scalp are affected next to the face in point of fre- 
quency, while the tumors may occur anywhere but on the 
palms and soles. 

Etiology. Children are far more often affected than 
adults. If adults are affected, it will usually be found 
that they are in attendance upon children who have mol- 



Fig. 60. 




Molluscum contagiosum. By the courtesy of Dr. J. A. Fordyce. 



luscum. The bad hygienic conditions under which poor 
people live seem to predispose to the affection, as it is 
rare to meet with it among the well-to-do. There is little 
doubt that the disease is contagious. Though inocula- 
tion-experiments have failed in most instances, still there 
have been a few cases in which they were successful. In 
the spring of 1891 a child with molluscum contagiosum 
came into my service in Kandall's Island Hospital, and 
within a few weeks, no attempt being made to destroy the 
tumors, there were six cases in the wards. 



MOLLTJSCTJM FIBROSTJM. 447 

Pathology. The true pathological anatomy of these 
growths has not been settled, but the old idea that they 
spring from the sebaceous glands is no longer entertained. 
The rete seems to be the starting-point of the disease. 
One of the most characteristic features of the disease is 
the so-called " molluscum corpuscle," which is but a 
changed epithelial cell. (Fig. 60.) These appear, 
under the microscope, as large, ovoid, lustrous bodies, 
without nuclei, some being either wholly or partly con- 
tained in an epidermic envelope, and some being entirely 
uncovered. Several parasites have been declared to be 
the cause of the disease by different investigators. Charles 
J. White and W. H. Robey, 1 after careful investigation, 
state that the disease is not parasitic, and that the mol- 
luscum bodies are an extraordinary metamorphosis of the 
rete cells into keratin. 

Diagnosis. The appearance of this disease is so charac- 
teristic as to be diagnostic. It is most apt to be confused 
with milium; but if it is remembered that a milium has 
no central depression, while a molluscum has, the confu- 
sion will exist no longer. If the lesions are taken for 
the vesico-pustules of variola, a scarely probable occur- 
rence, pricking their tops will at once show that they are 
not pustules, and if they are watched for a day or so it 
will be found that they remain unchanged. 

Treatment. The speediest way of getting rid of the 
tumors is to scrape them off with a curette. To insure 
their not returning it is advisable to touch the base of 
each tumor with a drop of carbolic or stronger acid. Or 
it is sufficient to make a small slit in the top of the 
tumor with a scalpel, squeeze out the contents, and touch 
the base with carbolic acid. If operative measures are 
refused strong boric acid lotions, or salicylic acid 3 per 
cent, in sulphur ointment may be used. 

Molluscum Epitheliale. See Molluscum contagiosum. 
Molluscum Fibrosum, seu Pendulum. See Fibroma. 

1 Journ. Med. Research, 1902, vii., 255. 



448 DISEASES OF THE SKIN. 

Molluscum Sebaceum, seu Verrucosum. See Molluscum 
contagiosum. 

Monilethrix. See Atrophia pilorum propria. 

Morbilli. Synonyms : Rubeola ; Measles. 

This is one of the contagious exanthemata. Its stage 
of incubation is from eight to twenty -one days, usually 
from ten to twelve days. It is characterized by prodro- 
mata of marked catarrhal symptoms, such as conjunctivi- 
tis, coryza, and bronchial inflammation, more or less fever, 
and constitutional disturbance ; and then, on about the 
third day, an eruption of small, red, flat papules that 
rapidly enlarge, and unite with others to form mulberry- 
colored little patches often of a crescentic shape, with 
areas of sound skin between. H. Koplik x calls attention 
to the fact that one or two days before the eruption ap- 
pears on the skin there will be found on the buccal mucous 
membrane and on the inside of the lips small, irregular, 
bright-red spots with a minute bluish speck in the 
centre. The eruption begins on the face and neck, 
spreads downward, and covers the whole body in about 
a day and a half. The fever begins to decrease on the 
second day of the eruption. The rash begins to disap- 
pear by the third or fourth day, and is gone by the ninth 
day. Furfuraceous desquamation follows the subsidence 
of the exanthem. Sometimes it is so slight as to be 
hardly noticeable, and it is never so marked as in scarla- 
tina. 

Diagnosis. The only dermatoses with which measles 
is apt to be confounded are an erythema, rotheln, or Ger- 
man measles, variola, and the macular syphilide. But 
the catarrhal symptoms ; the regular progression of the 
eruption from above downward ; and the crescentic patchy 
arrangement and dark color of the lesions are sufficient to 
differentiate it. In erythema we may have some constitu- 
tional disturbance, but it is of short duration ; the erup- 
tion is more pronounced on the trunk and extremities, 

i Arch. Pediat., Dec, 1896, 



MULTIPLE FUNGOID TUMORS. 449 

and shows no order of progression ; the color of the erup- 
tion is a brighter red ; there is an absence of crescentic 
arrangement ; and very often an accompanying urethritis 
will suggest the ingestion of some of the balsams as a 
cause of the trouble. In rbtheln there is not so much 
constitutional disturbance, less catarrhal complications, 
and a pronounced swelling of the glands of the neck. 
The eruption is usually a remarkably fine papular one, 
not so patchy as in measles and of shorter duration. 
Variola in its early stage is sometimes difficult to diag- 
nose from measles. Backache is usually a marked symp- 
tom in variola ; its papules are smaller, harder, and more 
shot-like, and lack the crescentic arrangement of measles. 
The subsequent course of the disease is, of course, very 
different from that of measles. The erythematous syphilide 
affects the sides of the chest and the abdomen more than 
the face ; the rash lasts for weeks after any possible fever 
has passed ; its lesions have no definite arrangement and 
come out in successive crops, so that at the same time 
there will be present lesions of different age, and staining 
of the skin from those that have gone. 
Treatment is purely symptomatic. 

Morbus Elephas. See Elephantiasis. 
Morbus Maculosus Werlhofii. See Purpura. 
Morbus Pedicularis. See Pediculosis. 
Morphcea. See Scleroderma. 

Morvan's Disease is a disease of the spinal cord which 
causes profound cutaneous lesions, such as ulceration, 
bullae, and fissures of the palmar side of the hands and 
fingers, and paronychia and necrosis of several phalanges. 
It is allied to, if not identical with, syringomyelia, which 
see. 

Morve. See Equinia. 

Moth Patch. See Chloasma. 

Mother's Mark. See Nsevus. 

Multiple Fungoid Papillomatous Tumors. See Mycosis 
fungoi'des. 



450 DISEASES OF THE SKIN. 

Myasis Externa Dermatosa is a dermatitis due to the 
penetration of the skin by eertain kinds of flies, which lay 
their eggs under the skin. These subsequently hatch out 
and give rise to the dermatitis. 

Mycetoma. See Fungous foot of India. 
Mycosis Frambcesiodes. See Dermatitis papillaris ca- 
pillitii. 

Mycosis Fungoides. Synonyms : Inflammatory fungoid 
neoplasm ; Multiple fungoid papillomatous tumors ; Fi- 
broma fungoides ; Lymphadenie cutanee ; Granuloma fun- 
goides ; Eczema hypertrophicum sen tuberosum ; Ulcer- 
ative scrofuloderma ; Lymphodermia perniciosa ; Sarcoma- 
tosis generalis ; Multiple sarcoma cutis ; Fungoid derma- 
titis ; Beerschwamahnliche multiple Papilla rgeschwulste 
der Haut. 

A chronic progressive disease of the skin, characterized 
by the appearance with or without an antecedent erythe- 
matous or eczematous stage, of fungating tumors that tend 
to break down and ulcerate. It leads, through marasmus, 
to death. 

Symptoms. The many names that have been applied 
to this rare disease testify to the uncertainty of our knowl- 
edge of its proper place in the classification of skin dis- 
eases. It assumes so many forms that it is impossible in 
our limited space to give a complete picture of the disease. 
In some cases the first thing noticed is what appears to be 
a simple eczema, erythema, urticaria, or psoriasis in vari- 
ously sized patches, tending to be round or circinate in 
form, and accompanied by marked pruritus. One char- 
acteristic of one variety of prodromal erythema is that the 
macules arrange themselves in circles in the centre of 
which is a single macule like a bull's eye. These lesions 
occur anywhere, and constitute the first stage of the dis- 
ease. They may disappear for a time, to reappear in the 
same places or elsewhere. After some months, or two or 
three years or more, the patches become raised, glistening, 
and infiltrated, more deeply red, and pea-sized papules 



MYCOSIS FUNG01DES. 451 

form. These disappear, and new ones form. This is the 
second stage, and may last months or years. Then the 
characteristic tumors form either by the papules enlarging 
and coalescing, or as tumors at once rising out of the 
sound skin, without antecedent erythematous stage. The 
tumors are oval, hemispherical, annular or irregular in 
shape, sharply denned, sometimes slightly pedunculated. 
They are of whitish, bright-red, bluish-red, or dark-red 
color. They are sometimes hard and elastic, sometimes soft 
and succulent. The epidermis over them is tense, thin, and 
glistening. They may be absorbed and disappear, new 
ones appearing ; or they may become necrotic and ulcerate. 
In size they vary from that of a pea to that of the fist. 
At first they occur only on the trunk and may limit them- 
selves to a single region ; later, they come anywhere, and 
involve even the mucous membrane of the mouth. When 
ulcers form from breaking down of the tumors they are 
horseshoe-shaped or crescentic with round broad edge. 
The itching and pain continue well into the tumor-stage, 
when they lessen. The lymphatic glands enlarge pain- 
lessly. The hair falls from over the tumors. The gen- 
eral health of the patient is undisturbed for a long time, 
but at last a general marasmus sets in and the patient dies, 
usually from an uncontrollable diarrhoea or some lung 
complication. There has been but one case of recovery 
reported. 

Etiology. The majority of the cases have been in 
men over forty years old. The disease is held not to be 
contagious by some, while others hold the opposite opinion. 
Blanc 1 found in one case that there was a marked reduc- 
tion in the white blood corpuscles, their proportion to the 
red being 1 to 130. instead of 1 to 350 or 500. Vari- 
ous microorganisms have been found in connection with 
the disease, but no one has been settled on as the cause. 
This is about all that is known of the etiology of the 
disease. 

Pathology. The earliest histological changes are 

1 Journ. Cutan. and Gen.-Urin. Dis., 1888, vi., 256. 



452 DISEASES 01 THE SKIN. 

oedema and dilatation of the bloodvessels and the lymph 
capillaries, often accompanied by some slight endothelial 
proliferation. Soon the corium is marked by an infiltra- 
tion which may be diffuse or circumscribed in irregular 
patches, spreading outward from the vessels. In the cen- 
tre of an infiltrated region the cells are densely packed and 
the structure bears a strong resemblance to an invading 
small round-celled sarcoma, but at the edges the true infil- 
trating granulomatous nature of the growth is always 
evident, and the multiform character of the infiltrating 
cells can more easily be made out. There are many small 
round cells, and fewer plasma, mast, multinuclear and 
giant cells, all of great diversity in size, shape and stain- 
ing qualities. Mitoses and cell fragments are numerous, 
and indicate concomitant cell proliferation and degenera- 
tion. Usually there is also some diapedesis of red blood 
corpuscles. 

At first the epidermis may be unaffected, but more often 
shows various changes such as oedema, acanthosis and 
parakeratosis. The rete may hypertrophy, mitotic figures 
appear, and the interpapillary processes become long and 
thick. But as the granulomatous tissue gradually increases 
in amount, causing the growth to project above the sur- 
rounding surface, the epidermis begins to show the effects 
of stretching and impaired nutrition, the rete thins out 
until it may consist of only a single layer of cells, and 
finally ulcerates. 

In the last stages there is extensive crenation or frag- 
mentary degeueration of the granulomatous cells accompa- 
nied by a basophilic disintegration of the fine collagenous 
and elastic tissue net work which supports the growth. 

While much study has been given to the pathology of 
the affection there is no agreement among pathologists 
as to its essential nature. By many it is supposed to 
belong to the class of infecting granuloma. 

Diagnosis. The diagnosis of the disease in its early 
erythematous stage is very difficult, and probably cannot 
be made with certainty. There is something peculiar in 



MYOMA. 453 

the sharply circumscribed outline, the chronicity, circinate 
form, and capriciousness of the patches. Psoriasis affects 
other localities at first, its patches are not so infiltrated, 
and it is more scaly. Eczema is a moist disease at some 
time and more multiform in character. When the tumors 
develop, and the capricious manner of their coming and 
going is observed, the diagnosis is more evident. 

Treatment. Xobner reports the cure of a case by 
means of hypodermic injections of arsenic. Crocker speaks 
encouragingly of sallcln in all stages before ulceration 
takes place. A general tonic treatment is always indicated. 
Locally, pyrogallol ; ichthyol ; mercurial ointment ; injec- 
tions of carbolic acid ; resorcin, and camphorated naphtol 
have been used, and may be tried. The itching is most 
rebellious to treatment. The tumors, when not in great 
numbers, may be cut out, though the operation is of 
doubtful utility. The ulcerations that result from break- 
ing down of the tumors must be treated on surgical 
principles. 

If recent experiences with R'ontgen rays should be 
borne out by further trial of them, we have a means of 
curing the intense itching and causing a complete disap- 
pearance of all the lesions. The patient is to be seated 
one or two feet from the target, and the affected skin 
flooded with the rays. In one case known to the writer, 
though at first relief from the itching was obtained and 
the tumors disappeared, later the itching returned and was 
uninfluenced by the rays. The skin also was deeply pig- 
mented. Nevertheless, it is the only treatment that has 
availed at all, and should be tried. 

Prognosis. Death is the outcome of the disease, and 
it may occur in from a few months to fifteen years, the 
average time being from two to four years. 

Mycosis Microsporina. See Chromophytosis. 

Myoma. Like most of the tumors, so this one concerns 
the surgeon more than the dermatologist. Two main 
varieties are described, namely, simple or liomyoma and 



454 DISEASES OF THE SKIN. 

dartoic. Myoriaata may be single or multiple. They are 
composed of muscular fibres, and vary in size from that 
of a split pea to that of an orange. They are painful on 
pressure, and sometimes spontaneously. They are pink 
or red, in color, or of that of the sound skin ; disseminated 
or aggregated into patches, though still retaining their in- 
dividuality. The epidermis over them is unchanged. 
The single tumors may be sessile or pedunculated, and 
may attain the size of an orange. The dartoic variety 
has its seat most often on the female breasts, and on the 
genitalia of both sexes, and is usually a single tumor. 
Simple myoma are more commonly multiple, and occur 
upon the upper extremities, though they may occur any- 
where on the body. Most of the cases are in middle-aged 
or elderly men. If they contain a good deal of fibrous 
tissue, they are called fibro-myoma ; if they contain large 
bloodvessels, they form angio-myoma ; or, if the lymph- 
atics are involved, we have lymphangio-myoma. The 
diagnosis is often difficult without the aid of the microscope. 
Excision is the only thing that can be done for them. 

Myoma Telangiectodes. See Myoma (Angio-myoma) 
Myxadenitis Labialis. See Cheilitis glandularis. 

Myxoedema. This is a constitutional disease with cu- 
taneous symptoms. The skin becomes waxy pale ; yel- 
lowish ; shining in some places, dull and earthy-looking 
in others ; it is dry, scaly, exfoliating on the extremities, 
sometimes ulcerated, and verrucose on the lower limbs. 
The fingers and toes are sometimes livid. There are 
partial or general alopecia, and deformity and fragility of 
the nails. There is a general oedematous swelling of the 
whole integument as well as of the mucous membranes, 
and this oedema does not pit on pressure. The swelling 
is most marked in the face. The skin about the eyes be- 
comes puffed up so as almost to close the eyes. Cushions 
of fat fill the supraclavicular spaces. There is atrophy 
of the thyroid gland. The patient's intellectual faculties 
become dulled, the speech is slow, and the gait unsteady. 



N^VUS PIGMENTOSUS. 455 

The disease affects women far more often than men, 
and involves all parts of the body. There are an enfee- 
blement of mind, and a great impairment of the senses of 
touch, taste, and smell ; a torpidity of movement and of 
the digestive functions. It ends fatally either by maras- 
mus or by complications on the side of the internal organs. 

The diagnosis in the early stage is difficult ; when fully 
developed it could hardly be taken for anything else. 
The cause of the disease is unknown. 

Treatment. All the symptoms are removed by the 
use of thyroid extract or powder, improvement being 
rapid. When the treatment is stopped the patients after 
a time lapse into their former state, so that the adminis- 
tration of the thyroid has to be more or less continuous. 

Naevus. A nsevus, strictly speaking, is a congenital 
mark or growth in the skin, which may be either pigmen- 
tary or vascular. The name is occasionally applied to 
acquired new growths similar to the congenital ones. 

Naevus Araneus. See Telangiectasis. 
Naevus Lupus. See Angioma serpiginosum. 

Naevus Pigmentosus. Synonyms : Nsevus spilus ; Nsevus 
pilosus ; Nsevus verrucosus ; Naevus lipomatodes ; (Ger.) 
Fleckenmal, Pigmentmal, Linsenmal ; Pigmentary mole ; 
Mother's mark. 

A congenital, circumscribed hyper-pigmentation of the 
skin, often accompanied by a growth of coarse hair and 
hypertrophy of the connective and fatty tissues. 

Symptoms. These growths are closely allied to lentigo 
and chloasma, as a hypertrophy of pigment is a promi- 
nent feature of them. When they consist of pigment 
only, and are not raised above the surface of the skin, 
they are called ncevus spilus. When besides the pigment 
there is an hypertrophy of the connective tissue, and they 
are raised and uneven, the name ncevus verrucosus is ap- 
plied to them ; or ncevus lipomatodes if they are soft and 
contain fatty tissue ; if hair grows from either form, then 
we speak of ncevus pilosus. In color they vary from a 



456 DISEASES OF THE SKIM 

light to dark browu or black. In size they vary from 
that of a split pea to that of an area large enough to cover 
the whole back. Most commonly they are of small size. 
They may be located anywhere, though most often on the 
face, neck, and back. There may be but one or two or 
hundreds of them. They may have no special distribu- 

Fig. 61. 




Nsevus lipomatodes. 

tion, or they may occur in streaks or bands. They may be 
unilateral or bilateral, and sometimes symmetrical. If hair 
is in them, it is coarser, stifFer, and generally darker than 
that of the head. Sometimes large hairy moles bear a strong 
resemblance to the fur of animals. They grow in pro- 
portion to the growth of the individual, and cease grow- 
ing when he has attained his growth. They are usually 
congenital, but may be acquired, and are liable to undergo 
malignant change in advanced life. They give rise to 
no subjective symptoms. They are permanent growths. 
They rarely disappear of themselves. 

Etiology. They are congenital growths, as a rule. 



NJEVUS PIGMENTOSUS. 457 

To account for the appearance of these malformations we 
have only the theory of nerve-influence, and that is by no 
means satisfactory. Their name of "mother's mark" 
shows that the popular superstition agrees with the 
scientific theory. We can simply regard them as ano- 
malies. 

Diagnosis. Moles differ from lentigo in being con- 

Fig. 62. 




Nsevus pilosus. (By the courtesy of Dr. S. Dana Hubbard.) 

geuital and permanent, and in a hypertrophy of connec- 
tive tissue and a growth of hair being connected with 
them. The difference between hairy moles and hyper- 
trichosis is in the substratum ; in the latter the underlying 
skin is otherwise normal. Moreover moles occur in 
definite patches. 

Treatment. We can destroy these growths and leave 
behind but little scar. If there is but a single pigmen- 
tary mole, it may be cut out. In this case it will leave a 



458 DISEASES OF THE SKIN. 

linear scar. It is generally better to destroy the growth 
by touching it over carefully with nitric or glacial acetic 
acid. This is done by stippling, as it were, making a row 
of dots in this fashion — 



At the time of the next visit a row of dots should be 
made in between, and so the stippling is to be continued 
until in course of time the naevus is destroyed. If done 
with care, and slowly the result is very good. Fuming 
nitric acid is best. Electrolysis by multiple punctures, 
or by transfixing the mole and making tracks in various 
directions, is a sure and speedy way. They may be de- 
stroyed by sparking with the high-frequency current. 
J. Brault 1 recommends tattooing them with a solution 
of 30 parts of chloride of zinc and 40 parts of sterilized 
water. The eschar falls in five to ten days. It may be 
necessary to repeat the process. Hairy moles are best 
destroyed by electrolysis, as in superfluous hair, only 
here a coarser needle may be used, as we are not so par- 
ticular about a little scarring. In extensive hairy moles 
Rontgen rays may be used to cause a fall of the hair, 
when we can work better with acids upon the pigmenta- 
tion. Freezing by liquid air, or the snow made by car- 
bon dioxide, is a speedy and reliable method. If done 
with care the scar is good. It is the method of choice. 
The warty growths may be removed by a curette. 

Naevus Unius Lateris. See Papilloma lineare. 

Naevus Vascularis. Synonyms : Naevus vasculosus seu 
sanguineus ; Angioma (Ger.) Feuermal, Gef assmal ; (Fr.) 
Tache de feu, Tache vasculaire ; Port-wine mark ; Birth- 
mark; Claret stain. 

Symptoms. These are composed mainly of vascular 
tissue, and are congenital or appear during the first month 
of life. They are usually single, but may be multiple. 

1 Ann. de derm, et de syph., 1895, vi., 33. 



NMVTJS VASCULARIS. 459 

They vary greatly in size, shape, and color, but all possess 
one feature in common — they pale under pressure. They 
may be pinhead-sized spots not raised above the surface of 
the skin ; or they may form large, erectile, elevated, pulsat- 
ing tumors ; or they may spread out so as to involve a 
large area. They may be pink, bright red, dark red, or 
even purple in color. When on the face they become more 
pronounced on crying, coughing, and the like. They 
may disappear spontaneously; increase in size during 
a few months or years ; or, most commonly, remain un- 
changed. According to their size they have received 
various names. The small, flat, or scarcely raised naevus 
composed of capillaries is called ncevus simplex, or capil- 
lary nsevus. This is the form very often seen in children, 
on the lips, or nape of the neck. It is not infrequent for 
it to disappear of itself after a while, leaving either no 
trace or a delicate atrophic scar. When it is so large as 
to form a patch as big as the hand or larger, it is called 
ncevus flammeus, or jwrt-icine mark. The surface of this 
form is often uneven and studded with small erectile 
vascular tumors, or, may be, pigmentary moles. It often 
becomes dark purple after exposure to cold. The large 
erectile pulsating tumors are called ncevus tuberosus, angi- 
oma cavernosum, venous ncevus. They differ very much 
from the other forms in appearance and formation. 
Their surface is uneven and lobulated. This form is 
apt to increase in size, and may attain enormous dimen- 
sions. Blue ncevi or benign melanoma are steel blue 
macules 3 to 4 mm. long, and 2 to 3 mm. wide, round 
or oval, looking like powder grains. At times some 
slight thickening of the skin may be felt. They are loca- 
ted on the extremeties or face, and usually there is but 
one. 

Nsevi may occur anywhere on the body, but are most 
frequent on the head and face. They may also occur 
upon the mucous membranes primarily or secondarily. 
The back, nates, pudenda, and lower limbs are said by 
Crocker to be the most common sites of the cavernous 



460 DISEASES OF THE SKIN. 

form. All forms of nsevi may be hardly perceptible at 
birth, but become gradually more evideut afterward. 

Etiology and Pathology. Vascular usevi are prob- 
ably always congenital malformations, though their ap- 
pearance upon the skin may be retarded for some time. 
Their frequent occurrence on the nape of the neck sug- 
gests local injury either during gestation or parturition. 
The simple capillary nsevi, which include the port-wine 
marks, are simply an increase in number and size of the 
capillaries. In the venous nsevi we have also a new 
growth of connective tissue forming a mesh work, and they 
are supplied directly by an artery without the interposi- 
tion of capillaries. Women are more prone to nsevi than 
are men. 

Diagnosis. There can be no difficulty in diagnosis, 
excepting that a nsevus may be taken for a telangiectasis. 
This error would be of little consequence, since the latter 
is simply an acquired nsevus, and differs chiefly in having a 
central red point from which the dilated capillaries radiate. 

Treatment. Electrolysis may be used for the de- 
struction of these growths. The current strength should 
be from 2 to 3 milliamperes. The best way to use it in 
capillary nsevi and port-wine marks is by making multi- 
ple punctures in parallel rows, perpendicularly to the skin 
and down through its entire thickness. To expedite 
matters, one may use either a circle of needles set in a 
handle, or a row of three needles. The negative pole is 
to be connected with the needle-holder, and the operation 
is to be cod ducted in the same way as in removing su- 
perfluous hair. By this method it is possible to destroy 
small nsevi entirely, and to diminish very much the un- 
sightly appearance of large port- wine marks. As elec- 
trolysis necessarily destroys the skin, a scar will be left. 
But this is less conspicuous than the nsevus, and if 
the operation is carefully done the scar is soft, smooth, 
and pliable. There is also much less danger of a de- 
forming scar from the use of a single needle than from a 
group of them. Therefore this method is preferable, 



NJEVUS VASCULARIS. 461 

though more tedious. The punctures must not be made 
close together ; at least a sixteenth of an inch should be 
left between them. After the naevus has been carefully 
gone over, it should be left alone for a couple of weeks 
or more for the full effect of the operation to be seen. It 
can be done over again, and another interval of time al- 
lowed, and so on till the growth is destroyed as much as 
possible. 

Besides electrolysis we may use multiple scarifications 
obliquely to the skin or sparking by the high-frequency 
current. Or we may use the ethylate of sodium freshly 
prepared and applied to the absolutely dry skin, using a 
brush or glass rod. To avoid scarring, only a small part 
of the naevus must be attacked at a time. A crust will 
form, which must be left to come away of itself. Fuming 
nitric acid or the acid nitrate of mercury may be stippled 
over the growth, care being had that the little dots are 
made in rows with spaces between equal to the size of the 
dots. At the next sitting the dots should be made be- 
tween the first ones. In this manner the stippling is 
carried out until the naevus is destroyed. Or vaccination 
may be performed over it. Or multiple punctures may 
be made by means of a steel needle dipped in nitric or 
carbolic acid. Marshall Hall advocates breaking up the 
naevus by introducing a cataract-needle close to the edge 
of the growth, pushing it across to the opposite side, then 
nearly withdrawing it, and again pushing it in at a little 
distance from the first puncture. These naevi have been 
cured by x-rays used to the point of causing dermatitis 
and vesiculation. The most brilliant cures I have seen 
made both of this and the cavernous naevus were by conge- 
lation. In some cases the scars left were hardly percepti- 
ble. It is not successful in port-wine marks. 

For cavernous naevus we may use electrolysis also, but 
here we pass the needle obliquely into the skin in the hope 
of striking the deep vessels. It is well, sometimes, to 
pass the needle from the edge deep under the naevus and 
clear through to the other side, let the current pass for 



462 DISEASES OF THE SKIN. 

half a minute, partially withdraw the needle, and again 
push it in another direction, so as to avoid scarring as 
much as possible. Some prefer introducing two needles, 
connected each with one pole of the battery, in opposite 
directions. A platinum or gold needle must be used with 
the positive pole. A current strength up to 5 milliam- 
peres is often necessary to destroy these growths. Exci- 
sion may be performed, but sometimes this gives rise to 
alarming hemorrhage. Multiple punctures with a steel 
shoemaker's awl, heated to a red heat and allowed to cool 
to a black heat, or the point of a Paquelin or galvano- 
cautery heated to a dull red, are other good methods of 
treatment. It has been proposed to use a metallic plate 
perforated with a number of holes with which to exercise 
strong pressure upon the nsevus while the galvano-cautery 
is introduced through the holes. Injections of carbolic 
acid, perchloride of iron, alcohol, and the like, are effect- 
ual but dangerous methods. Wyeth uses injections of 
water at a temperature of 180° to 200° F., injecting 10 
to 60 drops and repeating the injections every three or 
four days. There is some danger of embolism from this 
method. Setons are not used as much as formerly. 
Compression by an elastic bandage is at times curative 
when the nsevi are located over bony prominences. 

As many capillary nsevi in children disappear in time, 
it is advisable not to interfere with them at once, con- 
tenting ourselves with painting them with collodion and 
waiting until the child is old enough to desire their re- 
moval. Unna thinks that the addition of 10 per cent, 
of ichthyol to the collodion increases its efficacy. Of 
course, if they are very unsightly w r e cannot wait, nor 
should we temporize with cavernous nsevi. In children 
one works most comfortably by using an anaesthetic, but 
it is not absolutely necessary. Keloidal scars may be an 
unfortunate result of treatment in some cases. 

Prognosis. The prognosis should be guarded, and 
the cases carefully watched. All nsevi may increase in 
size, though very many remain stationary. 



NODOSITES DES ARTHRITIQUES. 463 

Nsevus Verrucosus. See Papilloma lineare. 
Narbengeschwulst. See Keloid. 
Nerven Naevi. See Papilloma lineare. 
Nesselausschlag. See Urticaria. 
Nettlerash. See Urticaria. 
Neuralgia Cutis. See Dermatalgia. 

Neuroma Cutis is an exceedingly rare disease, of which 
but a few cases have been reported. Neuromata are 
small, flat, pinkish or pale-red, firm tumors firmly imbed- 
ded in the skin. They are painful spontaneously and on 
pressure. The pain may be paroxysmal in character. 
They are relievable by cutting out part of the nerve with 
which they are connected. 

Neuropathic Papilloma. See Papilloma lineare. 
Nodositas Crinium. See Trichorrhexis nodosa. 
Nodositas Pilorum Microphytica. See Tinea nodosa. 

Nodosites Non-erythemateuses des Arthritiques. Brocq 
applies this name to cutaneous and subcutaneous tumors 
that he has met with in connection with the gouty diath- 
esis. They are of two varieties. The first one he calls 
ephemeral cutaneous nodules. They occur upon the fore- 
head and form ill-defined elevations of the skin, of small- 
pea to hazelnut size, and entirely painless. They are 
movable with the skin, though sometimes they are adher- 
ent. They appear first during the night and disappear 
within twenty-four hours. 

The second variety is the subcutaneous rheumatismal 
nodule. It forms a small tumor resembling a gumma. 
The skin slides freely over it in most cases. The color 
of the skin is unchanged. It is firm and elastic to the 
touch. Generally such tumors are painful on pressure, 
at times spontaneously. In size they vary from that of 
a pea to that of an almond, and they are sharply defined. 
They may remain for days or weeks, when they disap- 
pear, leaving no trace. They often come in successive 
outbreaks. Their seat of predilection is about the joints, 
and upon the fibrous tissues that cover the superficial 



464 DISEASES OF THE SKIN. 

bones. They are generally discrete, and frequently very 
numerous. Their appearance often coincides with symp- 
toms of pericarditis or pleurisy. Their treatment is that 
appropriate to the rheumatism that seems to be their 
cause, especially iodine and the iodides. 

Nodulus Laqueatus is that condition of the hair in which 
it seems to tie itself into knots. The hair is usually dry 
and curly. It is probably caused by handling of the 
hair, and does not occur spontaneously. 

Noli me Tangere. See Lupus vulgaris. It has been 
used as a synonym for rodent ulcer. (Crocker.) 

(Edema Cutis, Acute Circumscribed. This disease is also 
called angio-neurotic oedema, acute idiopathic oedema, peri- 
odic or giant swelling. It is a question whether this is a 
form of urticaria or not. It is certainly allied to it in the 
suddenness of its onset ; in the attending erythema and 
digestive or other constitutional disturbances ; and in the 
character of its lesions. It differs from urticaria in being 
recurrent in the same locations ; in the shading oif of the 
swellings into the surrounding skin ; and at times in being 
unattended by itching. It is prone to occur upon the 
face, and there often closes one or both eyes in an enorm- 
ous swelling ; or the lips so that the mouth cannot be 
opened. In some cases a history may be obtained of the 
occurrence of the same disease in other members of the 
family. It usually begins in early adult life and tends to 
recur. It may occur on the mucous membranes, causing 
suffocative attacks if the larynx is involved, and acute 
digestive disturbances if the stomach is affected. It occurs 
in various parts of the body as swellings which may be the 
color of the normal skin, pinkish, or dull red, that appear 
suddenly and disappear in a few hours, or persist for 
several days. While these do not itch, the patient com- 
plains of burning, tension, and throbbing. In the pres- 
ent state of our knowledge it is probably well to regard 
it as urticaria oedematosa. The treatment is the same as 
in urticaria. (See Urticaria.) 



ONYCHAUXIS. 465 

(Edema Neonatorum. This disease was formerly con- 
founded with sclerema, but is now separated from it. 

Symptoms. It is a rare disease, that begins upon the 
legs within the first three days of life. The oedema 
spreads upward along the thighs, shows itself upon the 
hands, then upon the genitals and back. It may begin 
on the back or face, or the hands may be affected at the 
same time with the legs. It is hard and pits only on 
deep pressure. The skin is of a violaceous red or more 
or less intense yellow, and feels cold. The infant is com- 
atose ; its pulse is feeble ; its breathing labored ; and its 
cry sharp. A high temperature may exceptionally be 
present. Death usually results on account of some pul- 
monary affection or from collapse. Exceptionally, re- 
covery takes place. 

Etiology. The disease occurs in feeble, ill-nourished 
children, in those prematurely delivered or exposed to 
poor hygienic surroundings. 

Diagnosis. It differs from sclerema in being more 
limited to certain localities ; in the skin being more livid 
from the first, and not so hard ; in affecting the depend- 
ent parts ; and in lacking the stiffness of the joints. (Crocker.) 

Treatment. Though the prognosis is exceedingly 
bad, an attempt should be made to nourish the child as 
well as possible by artificial feeding ; it should be wrapped 
in flannel and kept warm ; and the limbs should be rubbed 
with warm oil, or camphorated alcohol, in such a way that 
the blood is forced toward the heart. 

(Eil de Perdrix. A soft corn. 
Oligotrichia. See Alopecia. 
Onychatrophia. See Atrophia unguium. 

Onychauxis, Onychogryphosis. These are both hyper- 
trophies of the nail, either in length, breadth, or thick- 
ness ; or in all at the same time. When the growth is 
markedly forward and the nail is much thickened, it is 
called onychogryphosis. The nail in these instances gen- 
erally turns to one side after reaching a certain length, 
30 



466 DISEASES OF THE SKIN. 

sometimes so much so that a big-toe-nail may lie over the 
second and third toes. If the hypertrophy is lateral, we 
are apt to have onychia — ingrowing toe-nail. The hyper- 
trophied nail is rugous, but highly polished, brown, and 
there is often an accumulation of scales under it, which at 
times gives rise to a bad odor from decomposition. The 
toe-nails are those most often hypertrophied, but the finger- 
nails may be so affected. 

Etiology. Badly fitting boots and neglect of proper 
care of the nails are causes of onychauxis and onycho- 
gryphosis. They often arise without discoverable cause. 
They may be due to a congenital predisposition. They 
very often occur as part of some chronic skin or constitu- 
tional disease, such as eczema, psoriasis, leprosy, syphilis, 
and ichthyosis. The thickening may be due to disease of 
the matrix or to a thickening of the horny layer only. 

Treatment. The hypertrophied nail may be removed 
by mechanical means, such as by a file, saw, or knife. 
The continued use of salicylic acid sometimes will cause 
the thickened mass to fall off. The oleates of tin and 
lead ; the continuous wearing of rubber cots ; and liquor 
potassse, are also efficacious in softening the thickened 
mass of the nail. The action of all these agents is as- 
sisted by daily removing the softened layers by mechan- 
ical means. When the hypertrophy is but a part of some 
other disease it will be benefited by the same means as 
will benefit the cause from which it arises. If it is due 
to an inflammatory disease of the nail-bed or matrix, that 
must receive attention. (See Onychia and Paronychia.) 
After the nail deformity has been overcome it may return. 

Onychia or Onychitis. By this is meant acute inflamma- 
tion of the matrix of the nail-bed. The end of the finger 
or toe is reddened and swollen, and there is more or less 
throbbing pain. The nail is lifted from its bed, more or 
less pus escapes from underneath it, and it is eventually 
shed. The inflammation often spreads to the adjacent 
parts of the finger, and then we have that condition com- 



ONYCHOMYCOSIS. 467 

monly called ivhitlow. When the nail falls a spongy 
nail-bed is left, often with exuberant granulations. Under 
proper treatment a good nail may be reproduced, though 
in many cases either a very much deformed one will result 
or one that differs somewhat in appearance from the other 
nails. In some cases, instead of this phlegmonous form, 
we have a dry inflammation that is known as onychia sicca. 
Here the nail is discolored, its edge thickened and brittle, 
its surface rough and more or less pitted. Eventually the 
nail is shed. This condition is met with most often in 
syphilis. A chronic onychia is occasionally seen, and is 
one of the causes of onychauxis. 

Etiology. Onychia is due to traumatism or to some 
other disease of the skin, such as syphilis, eczema, psoria- 
sis, parasitic diseases, dermatitis exfoliativa, rheumatism, 
and the strumous state. 

Treatment. The treatment of onychia varies with 
the stage of the disease and with the cause. Occurring as 
part of some general disease of the skin, the treatment ap- 
propriate to the general disease will be beneficial to the 
onychia. Arising as an independent disease, or resulting 
from traumatism, the application of a 10 to 20 per cent, 
resorcin ointment or plaster, or painting with tincture of 
iodin, will often abort the disease in an early stage. The 
liquor alumeni acetatis kept constantly applied is an ex- 
cellent application. Ichthyol, 25 to 50 per cent, in oint- 
ment form is also useful. Stelwagon advises soaking the 
nail in a warm solution of bicarbonate of soda, 4 to 5 
grains to the ounce, if the nail is hard and inelastic ; also 
painting it with a 2 to 5 per cent, solution of nitrate of 
silver in sweet spirits of nitre. If the disease has gone 
on to suppuration, surgical procedures will have to be 
resorted to, such as splitting of the nail or its removal 
as a whole, and subsequent dressing with iodoform, aris- 
tol, or a bichloride solution. 

Onychomycosis. This term means the invasion of the 
nail by a fungus, such as the trichophyton or achorion. 
For further information see Trichophytosis and Favus. 



468 DISEASES OF THE SKIN. 

Osmidrosis. See Bromidrosis. 

Osteosis Cutis. A case of osteosis of the skin of the foot 
was reported by Sherwell 1 in 1892. It involved the 
plantar surface of the left foot about the heel and on the 
fourth toe. The patches were of cartilaginous hardness, 
with horny surfaces studded with nodosities. The patches 
were fairly movable over the underlying parts. They 
were painful when stepped on. The patient was a girl six 
years old. The patches were excised, but formed again 
within six months. A histological examination by Cole- 
man 2 showed that they contained cancellous bone. 

Pachydermatocele. See Dermatolysis. 
Pachydermia. See Elephantiasis. 

Paget's Disease of the Nipple. Synonyms : Mamillaris 
maligna ; Malignant papillary dermatitis; Epitheliomatose 
eczematoide de la inamelle (Besnier). 

Symptoms. This is a rare disease of the skin that is 
named after Paget, who first described it in 1874. 3 

It usually occurs in women over forty years of age, and 
at first has the appearance of an eczema madidans — that 
is, it presents "a florid, intensely red, raw surface, very 
finely granular, as if the whole thickness of the epidermis 
had been removed. From such a surface, on the whole or 
greater part of the nipple and areola, there is always a 
copious, clear, yellowish, viscid exudation." Besnier be- 
lieves that its primary stage is a keratosis, which, under 
any irritation, assumes an eczematous appearance. The 
edge of the patch is sharply defined and slightly raised. 
Sometimes, instead of the raw surface, we have crusting, 
or even scaling. Telangiectases may be seen here and 
there. After months or years marked induration is mani- 
fest, pinching up the patch imparting the sensation, as 
described by Mr. Morris, of "a penny felt through a 
cloth." Burning or itching is complained of, which makes 

1 Journ. Cutan. and Gen.-Urin. Dis., 1892, x., 119. 

2 Ibid., 1894, xii.,185. 

3 St. Bartholomew's Hospital Reports, vol. x., p. 83. 



PAGET S DISEASE OF THE NIPPLE. 469 

the disease the more nearly resemble an eczema. But it 
does not yield to the ordinary treatment of eczema, and its 
border gradually extends. The female breast, usually the 
right one/ is the most often affected, and there it always 
begins at the nipple, spreading theuce over the areola and 
skin. After a few months, or perhaps not for twenty years, 
signs of scirrhous cancer appear. The nipple becomes 
more and more retracted and ulcerated. Shooting pains 
are complained of. Hard nodules develop in the raw 
surface or deep down in the skin. The mammary gland 
itself may become affected. The disease in most cases is 
-unilateral. The cancerous cachexia develops later with 
ganglionic enlargements. The disease has been reported 
as occurring on the scrotum, the male nipple, glans penis, 
vulva, axilla, umbilical region, and buttocks, but these 
are exceptional sites. 

Pathology. It is still an open question whether the 
disease is malignant from the start, or, beginning as a 
simple inflammation, becomes malignant, just as we find 
epithelioma of the tongue developing upon a leucoplakia. 
Later investigations seem to indicate that the process is 
epitheliomatous from the beginning. J. A. Fordyce's 2 
investigations show the disease to be an " inflammation of 
the papillary region of the derma leading to oedema and 
vacuolation of the constituent cells of the epidermis, fol- 
lowed by their complete destruction in some places and 
abnormal proliferation in others." He holds that the 
disease spreads down the lactiferous ducts from the skin. 
O. H. Schultze 3 believes that the disease is not an epi- 
thelioma either as to the skin or the tumor in the breast. 
The latter he finds to be an adeno-carcinoma, but he 
offers no theory to account for the connection between 
malignant papillary dermatitis and the duct carcinoma. 
The changes in the lactiferous ducts are secondary. 

Diagnosis. Though very important, it is exceedingly 

1 Wickham : Maladie de Paget, Paris, 1890. 

2 New York Med. Journ., 1897, lxvi., 445. 

3 Journ. Cutan. Dis., 1903, xxi., 201. 



470 DISEASES OF THE SKIN. 

difficult at first to differentiate positively a case of Paget' s 
disease from an eczema. Eczema of the nipple is very 
common during the childbearing period, while Paget's 
disease occurs most commonly after the climacteric. In 
eczema we do not have, as a rule, the raw granulating 
surface of Paget's disease, while we do have more varia- 
tion in the course of the disease, exacerbations, and seasons 
of apparent quiescence. In eczema the patch is not so 
sharply denned, and its border is not raised ; about it there 
are apt to be outlying pustules or vesicles, and there is 
not the papyrus-like induration. When the nipple be- 
comes retracted and ulcerations take place, together with 
shooting-pains and enlarged lymphatics, the diagnosis is 
easy. 

Treatment. At the beginning, and while the diag- 
nosis is still doubtful, the usual remedies for eczema should 
be tried. If these fail, as they will if the disease is not 
eczema, or if the right diagnosis is arrived at, powerful 
caustics must be used, if the disease is still superficial. We 
may use, as recommended by Darier, a solution of chlo- 
ride of zinc, 1 in 3, to produce an exfoliation of the dis- 
eased epidermis, and follow it with a mercurial plaster, 
alternating with iodoform or aristol. Or a chloride of 
zinc paste may be kept on, spread thickly on lint, for four 
to six hours, and the slough poulticed off or allowed to 
separate under wet boric lint, or under oiled silk, as recom- 
mended by Crocker. Fuchsine in ointment, 1 grain in- 
creased to 5 grains to the ounce cured one case in Elliot's 
hands. 

The paste used in the Middlesex Hospital in these 
cases is made as follows : 

R Zinci chlorid., 

Liq. opii sed., 

Amyli, 

Aquae, gj ; 32 M. 

S. Ft. pasta., 

When there is ulceration, but not much induration, the 
surface should be thoroughly curetted and dressed anti- 



3iv; 


k 16 


3iv; 


16 


3iss; 


6 


31; 


32 



PAPILLOMA. 471 

septically. When nodules have formed and there is 
marked induration under an ulcerated surface, the whole 
diseased surface must be freely excised or the breast re- 
moved entire. In fact, it seems to me best to amputate 
the breast as soon as the diagnosis is made, when the 
patient is past the childbearing period. If an operation 
or the use of caustics is inadvisable for any reason, relief 
to the pain and discomfort may be had by dressing with 
a fuchsine solution 1 per cent, strength. X-rays have 
cured some cases, and are always indicated in inoperable 
cases or those refusing operation. 

Panaris Nerveux of Quinquaud belongs to that group 
of obscure diseases in which stand Morvan's disease and 
syringomyelia. It is characterized by swelling of the 
extremities, slight redness, and attacks of intense pain, 
terminating in eight to fifteen days by fissure of the finger- 
end and fall of the nail. Sometimes the skin of the finger- 
end becomes sclerosed and atrophied. 

Brocq advises in its treatment the constant applica- 
tion of chloroform liniment, and of irritant lotions or 
frictions to the cervical region and along the course of the 
nerves supplying the parts. Internally, he advises the 
valerianate of ammonia or of quinine. 

Panaritium. See Paronychia. 
Panne hepaticuie. See Chloasma. 

Papilloma. By this term is meant a papillary out- 
growth from the skin. Such are common warts, ver- 
rucous eczema, papillary excrescences following ulcera- 
tion, Kaposi's dermatitis papillaris capillitii, ichthyosis 
hystrix, nsevus unius lateris, and the like. The term is, 
therefore, of uncertain significance. Some authors have 
described papillomata apart from the above-designated 
diseases, and Hardaway reports at length a case of gen- 
eral idiopathic papilloma in a seven-months-old child. 
Mental defects have been noted in some of these cases. 
A muco-purulent secretion often is present, welling up 
between the papillae. The condition is a rare one. Under 



472 



DISEASES OF THE SKIN. 



the name of papilloma area elevatum Beigel has described 
one of these rare cases. 

Papilloma Lineare. Called also papilloma neuroticum, 
ichthyosis hystrix, nerve ncevus, ncevus unius lateris. This 
disease is commonly described under ichthyosis. As it 

Fig. 63. 




Papilloma lineare. (Foxi.) 

has no symptom in common Avith that disease, it is best 
to regard it as a separate disease. It occurs in the 
form of warty, papillary growths that may be isolated 
though grouped, and of pinhead size ; or they may be 
massed together^ into elevated, dark-green plates tra- 

i G. H. Fox, The Skin Diseases of Children, New York, 1897. 



PARAKERATOSIS VARIEGATA. 473 

versed by deep lines ; or arranged in long parallel rows. 
These growths may occur on only one side, and in a 
single region ; or on both sides of the body and in several 
regions. They sometimes seem to follow the course of 
nerves in their distribution. Pruritus is sometimes com- 
plained of. While often congenital, they sometimes do 
not develop until a number of years after birth, and all 
tend to increase until early adult life. The peculiar ar- 
rangement of the lesions distinguishes the disease from 
ordinary warts. 

The treatment consists in scraping away the growths 
with a curette ; or applying a 10 or 20 per cent, oint- 
ment or plaster of salicylic acid. 

Parakeratosis Scutularis. 1 Under this name has been 
described a disease that occurred on the scalp of a man 
forty-one years old. The whole scalp, with the exception 
of a strip at the periphery, was covered by a thick, greasy 
crust that enveloped the hair in bundles. Some single 
hairs had on them cuffs of yellowish- white, waxy, horny 
substance, one inch or more long, that were in connection 
with the crusts on the scalp. The growth of the hair 
was not much interfered with. At the edge of the scalp 
was a hairless, red, dry, and rough strip. 

Parakeratosis Variegata. Synonyms : Dermatitis psori- 
asiformis ; Dermatitis variegata ; Erythrodermie pity- 
riasique en plaques ; Lichen variegatus ; Psoriasiform 
and lichenoid exanthem. 

Symptoms. This disease was first described by Unna. 2 
It occurs as a generalized eruption, the face being often 
spared, in the form of patches which are oval or round 
and arranged so as to include healthy areas of skin in the 
groups, giving the skin a reticulated appearance. The 
patches are smooth or covered with fine delicate scales. 
Scattered among them at times are flat pinhead-sized 
papules with a small scaly centre. The general color of 

1 Internat. Atlas of Rare Skin Disease, No. 3. 
2 Monatshefte f. prakt. Dermat., 1890, x., 404. 



474 DISEASES OF THE SKIX. 

the eruption is pale lilac, but it may be red, disappearing 
under pressure, or brownish in tint. The patches fade 
in warm weather, but reappear in cold weather. The 
disease is chronic, lasting in spite of treatment for years. 
There is, as a rule, no subjective symptom. There may 
be some itching. 

Diagnosis. It differs from psoriasis in lacking the 
characteristic scaling of that disease and in the very super- 
ficial character of the patches. It differs from lichen planus 
in its color, in not specially involving the sites of lichen, 
in the absence of itching, and the character of its scales. 

Treatment is unavailing. 

Parasitic Diseases. The diseases of the skin caused by 
parasites may be divided into two classes : 1. Those due 
to vegetable parasites. 2. Those due to animal parasites. 

Group 1 comprises favus, ringworm, chromophytosis, 
erythrasma, and pinta. These will be found described 
under their proper headings. In 1899 E. Lusk 1 reported 
a case whose symptoms resembled those of scabies, but it 
was due to mucor corymbifer that was found escaping 
from the vesicles. 

Group 2 comprises a large variety of parasitss. Scabies 
and pediculosis, due respectively to the acarus and pedi- 
culus, are described at length in this book. Besides these 
we have — 

The leptus autumnalis, harvest-bug, or mower's mite, 
that bores its head into the skin, causes great itching, and 
induces violent scratching and consequent excoriations. 

The demodex follicidorum is described in relation with 
the comedo. 

The pulex penetrans, chigoe, or jigger, that resembles a 
flea, but penetrates under the skin with its head, sets up 
inflammation and, perhaps, ulceration and gangrene, and 
has to be dug out of the skin with a blunt needle. 

The pulex irritans, or common flea, whose bite causes 
an urticarial eruption in susceptible individuals. It is 

iMed. Rec, 1899, lvi., 204, 



PARONYCHIA. 475 

distinguished from that disease by having a hemorrhagic 
spot in the centre, and in the lesions being grouped. 
Powdering the underclothing with insect powder is a pro- 
tection against fleas. Stelwagon recommends the wear- 
ing a piece of camphor in a small bag under the clothes 
for the same purpose. 

The cimex ledularius, or common bedbug, attacks the 
skin for its food, punctures it, and at the same time in- 
jects an irritating fluid to increase the hyperaemia and the 
food supply. A wheal, or raised red spot with a central 
puncture, follows the bite, and a purpuric spot results. 
The irritation is relieved by any of the means serviceable 
in urticaria. 

Gnats and mosquitoes and their effects are all too famil- 
iar to require extended notice. 

Ixodes, or wood- ticks, the Jilaria sanguinis and jilaria 
medinensis, the tenia solium, and the eehinococcus, all find 
lodgment at times in the human skin. These parasites 
do not exhaust the list, but are the principal ones. 

Parchment Skin. See Atrophia cutis. 

Paronychia. This affection is popularly known as a 
whitlow, run-around, or ingrowing toe-nail. Ingrowing 
toe-nail results from the nail shoving or being shoved 
into the soft parts, either on account of disease of the nail 
itself, or of ill-fitting shoes, or of injury. The big toe- 
nail at its inner or outer edge, is the most common site 
of the disease, though any toe may be affected. The 
finger-nail may suffer, the inflammation being set up by 
some injury or infection. The furrow, fold, and bed of 
the nail all become inflamed, ulcerated, and exquisitely 
tender, and painful, the pain being of a throbbing char- 
acter, with the discharge of more or less pus. It is said to 
be more common in young people than in old, and far 
more frequent in men than in women. Paronychia of 
either the ulcerative or non-ulcerative form is frequently 
met with in syphilis. 

Treatment. Severe cases of paronychia most often 



476 DISEASES OF THE SKIN. 

find their way to the surgeon's hands. In syphilitic par- 
onychia general antisyphilitic treatment is required. In 
the non-ulcerative form mercurial ointment, diluted with 
one or two parts of diachylon ointment, may be used, or 
the mercurial plaster. The liquor alumeni acetatis kept 
constantly applied is an excellent remedy. In the ulcer- 
ative form the parts should be cauterized with nitric acid 
or a strong solution of acid nitrate of mercury, followed 
by water-dressings. Afterward the part may be dressed 
with iodoform or aristol. Bandaging, strapping, with 
mercurial plaster, and the use of rubber cots are also use- 
ful methods of treatment. 

In ingrowing toe-nail a wedged-shape piece should be 
cut out of the free edge of the nail and the nail should be 
filed down the middle, or, if that does not relieve the pres- 
sure, it may have to be removed in part or entire. 
The insertion of borated lint between the nail and the 
nail-fold, or using boric acid in powder first and some 
threads of lint or a little absorbent cotton to separate the 
parts, and strapping the toe with adhesive plaster, will 
also answer well. If ulceration has taken place, the 
ulcerated surface should be dressed with iodoform or 
aristol. If the ulceration be covered with exuberant gran- 
ulations, they should be touched with the nitrate of sil- 
ver stick. As a preventive of the trouble, wearing well- 
fitting shoes and keeping the nails clean and cut down 
the middle are the best means at our command. 

Paxton's Disease. See Tinea nodosa. 

Pediculosis. Synonyms : Phthiriasis ; Morbus pedicu- 
laris ; Pedicularia ; Lousiness. 

Symptoms. There are three varieties of lice that in- 
fest the human species, namely, the pediculus capitis, 
pediculus vestimentorum, and pediculus pubis. Though 
they all belong to one family, they differ among them- 
selves, and have distinct regions which they invade. 

The pediculus capitis infests the head only, and of that 
the occipital region and the parts over the ears are the 



PEDICULOSIS. 477 

common seats of invasion. From these it generally 
spreads to the parietal region, which is one of the best 
places in which to seek for nits, and, maybe, all over the 
scalp. Nits of all species of lice are small, pear-shaped 
light yellow or light brown, hard, shiny bodies fastened 
on one side of the hair, from which they are removed 
with difficulty. There are but one or many nits on a 
hair. The lice cause irritation of the scalp both by their 
movements and by the insertion of their haustellum into 
follicles of the skin for feeding purposes. Lice have no 
mandibles. There is no such thing as a louse-bite. They 
simply suck their nutriment by inserting their haustellum 
into the follicles of the skin. The victim scratches to re- 
lieve the itching and irritation, and this gives rise to a 
dermatitis of eczematous character with the production of 
large pustules. A fully developed and characteristic case 
shows the hair in the occipital region matted together 
with a sticky secretion and, it may be, blood-crusts, more or 
less eczematous lesions and large crusted pustules scattered 
over the Avhole scalp, enlarged lymphatic glands in the 
neck, and perhaps a few small pustules on the neck and 
face. When a patient presents himself with a pustular 
eruption on the neck, or with a number of large, crusted 
pustules scattered over the scalp, pediculosis capitis should 
always be suspected, and search made for the pediculi or 
their nits upon the occipital and parietal regions. Very 
often no pediculi can be found ; but if the disease is 
pediculosis, the nits will be discovered in the localities 
mentioned. ; 

T\\epediculusvestimentorum, or body-louse, inhabits the 
seams of the clothing, where it lays its eggs, and which it 
leaves only for the purpose of feeding upon the skin. It 
inserts its haustellum into the follicles of the skin, and 
thus produces a small hemorrhagic spot, even with the 
surface of the skin, which is a pathognomonic lesion of 
the disease. This feeding gives rise to itching, and the 
victim scratches to relieve it, thus producing a second 
symptom, excoriations. These have one peculiarity, which 



478 DISEASES OF THE SKIN. 

is, that they are very apt to take the form of long, parallel 
scratch-marks, because the patient digs into his skin with 
all four nails at once. Moreover, as the lice live by prefer- 
ence in the shirt-band at the back of the neck, these long 
scratch-marks are most often seen over the shoulders. 
Whenever they are seen we should suspect lice. Excori- 
ations are also seen on the inside of the limbs in locations 
corresponding to the seams of the clothing and about the 
waist corresponding to the location of the waist-band In 
certain individuals, besides excoriations and hemorrhagic 
specks, we will find ecthymatous pustules, ulcerations, and, 
in very old cases, a great deal of pigmentation, so that 
the skin appears as if affected with a general chloasma. 
Any of these symptoms — hemorrhagic specks, excoriations, 
and itching, which is incessant in pronounced cases — should 
lead us to suspect lice, and a careful search of the seams 
of the clothing will reveal them, unless the patient has 
changed everything before coming to us. It must be re- 
membered that the lice dwell both in linen and woollen 
clothing, and in bad cases, in the bedding also. W. A. 
Jamieson x has found in many cases that the lanugo hairs, 
especially on the back and shoulders, have nits on them, 
and believes that this fact accounts for the relapses often 
seen in the disease. 

The pediculus pubis, crab-louse or morpion, has a far 
wider feeding range than the other varieties. Though its 
favorite habitat is the pubic region, it may be met with 
upon the hair of the abdomen, chest, axillae, beard, eye- 
brows, and eyelashes. Itching, excoriations, eczematous 
lesions and nits on the hair are the symptoms it gives rise 
to, though the disturbance is not so great as that caused 
by the other forms of lice. The nits are rounder than 
those of the head louse and darker in color, sometimes 
looking like small concretions on the hair. It is the 
least common variety. It requires careful search and a 
sharp eye to discover the vermin at times, as they are 
almost transparent, and usually are attached to the hairs 
1 Brit. Journ. Dermat., 1899, xi., 193. 



PEDICULOSIS. 479 

head downward, and close to the skin. Cobbold taught 
that the pediculus that inhabits the eyelashes was a dis- 
tinct species, the pediculus palpebrarum ; but by most 
authorities the distinction is not made. In some cases, 
instead of red punctate marks, we find dull or slaty-gray, 
or pale-blue, lentil- to split-pea-sized macules scattered 
over the pubes, abdomen, extensor surface of the arms, 
axillae, and inside of the thighs. These are known as 
maculce ccerulece, or taches ombrees. They do not disap- 
pear on pressure. They last for a few days, and then 
disappear of themselves. To give rise to these spots there 
must be a predisposition on the part of the skin. Most 
of the few reported cases have been in debilitated sub- 
jects. According to Duguet, 1 the macules are produced 
by the emptying of the contents of the salivary glands of 
the louse beneath the human epidermis. 

Etiology. These different varieties of pediculosis are 
due to different varieties of lice. The head-louse (Fig. 64) 
is about two millimeters long and one millimeter broad, 
with a triangular head and broad thorax and short legs. 
The body-louse (Fig. 65) is larger than the head-louse, 
being two or three millimeters long, with a more oval head 
and longer legs with more developed claws. The pubic 
louse is broader and natter than either of the others, with 
rounder head, longer, stronger, and more claw-like legs, 
resembling somewhat a crab (Fig. QQ). The color of the 
lice is gray or white. They propagate with great rapidity, 
the young hatching out in six or seven days, and being 
capable within eighteen days of propagating their species. 
It has been calculated that two female lice might become 
the grandmothers of 1 0,000 lice in eight weeks' time. The 
pediculus capitis deposits its eggs close to the scalp and 
secretes a glue-like substance that sticks the ova to the hair. 
There may be but a single ovum on a hair, or many of them. 
The distance of the nit from the scalp shows the length of 
time that the disease has existed. As it takes the hair about 
a month to attain the length of three-fourths of an inch, if 
iGas. desHop., 1880, liii.. 362. 



480 DISEASES OF THE SKIN. 

we find the nit that distance from the scalp we know that 
it was deposited at least one month before. The severity 
of the symptoms to which the lice give rise will vary with 
the individual, some people being far more susceptible than 
others. Infection takes place from other people or from 
infested body or bed clothing. Women and children are 
the most frequent victims of pediculosis capitis ; adults, 

Fig. 64. Fig. 65. 





Pediculus capitis.— Male. Pediculus vestimentorum. 

(After Kuchenmeister.) (After Kuchknmeistee.) 

and especially elderly people, of pediculosis vestimento- 
rum. Pediculosis pubis is most frequently contracted 
during sexual intercourse, and is, therefore, most common 
in young adults. Dirt and uncleanness favor all forms, 
though even the most cleanly may at times harbor vermin. 
M. Oppenheim 1 has found a green coloring-matter in the 
cells of the corpus adiposum of the pubic louse, and when 
these pigment-bearing lice are more abundant than the 
non-pigment-bearing ones, the more blue spots there are. 
He thinks that the blue color is due to the action of a 
salivary ferment upon the human blood. 

Diagnosis. Pediculosis capitis needs to be diagnosti- 
cated from eczema. The characteristic location of its 

1 Archiv. f. Derm. u. Syph., 1901. lvii., 235. 



PEDICULOSIS. 481 

lesions upon the occipital region and nape of the neck, 
with its scattered and discrete large pustules over more or 
less of the scalp, should always suggest pediculosis ; then 
if the lice or their ova are found by searching the hair, 
the diagnosis is established. Nits here, as elsewhere, are 
differentiated from epidermic scales by being located upon 
the side of the hair, while the scale has a hair passing 
through its centre (Fig. 66). The nit, too, is of a yel- 

Fig. 66. 




Pediculus pubis. (After Schmaeda.) 

lowish color, somewhat pear-shaped, with its larger 
rounded end upward ; and it adheres closely to the hair, 
so as not to be readily removed. It is not always easy 
to distinguish pediculosis vestimentorum from pruritus 
cutaneus, especially if at the time the patient presents 
himself he has clean clothes on throughout. Both may 
occur in elderly people, and both may last a long time with 
no other lesion than scratch-marks. In pruritus we may 
find evidences of atrophic skin changes ; the itching is of- 
ten paroxysmal, and made worse by the patient becoming 
overheated. If we find the parallel scratch-marks over 
the shoulders and the hemorrhagic specks, we can make 
a positive diagnosis of pediculosis. From urticaria pedi- 
culosis vestimentorum differs in having hemorrhagic 
31 



482 



DISEASES OF THE SKIN. 



specks and in the parallel scratch-marks. Urticaria 
may complicate a pediculosis. Scabies differs from pedic- 
ulosis in appearing by preference upon the anterior face of 
the wrists, upon the breasts in females, upon the penis of 
males, and about the umbilicus of both 
Fig. 67. sexes. Its lesions are not long, par- 

allel scratch-marks, but small scratched 
papules. If the lice or their ova can 
be found in any case, the diagnosis of 
pediculosis is made easy. Dermatitis 
herpetiformis differs from pediculosis in 
wanting the parallel scratch-marks and 
in the markedly grouped character of 
its lesions. There will often be found 
groups of vesicles scattered about the 
skin. There can be no difficulty in 
diagnosing pediculosis pubis. Any 
itching about the pubic region should 
lead to an investigation, which, if care- 
fully made, will reveal the pediculi or 
their nits. 

Treatment. The most ready means 
of curing the disease when in the hairy 
regions is to shave the hair off and 
make some emollient application to the 
scalp to cure the eczema. But this is 
not advisable, excepting in children and 
in men in hospitals, and is not necessary. 
The most speedy and practicable method 
in public practice is to soak the hair of 
the head or pubic region with raw petro- 
leum or kerosene, with an equal amount 
of sweet oil. This may be done night 
and morning for two days, and the parts 
then washed with soap and water. This will effectually 
kill all the lice, and probably destroy the life of the ova. 
The latter must be removed for fear that they are not dead, 
aDcl for this purpose we may use a fine- toothed comb to 



Ova of head-louse 
attached to hair. 
(After Kaposi,) 



PELLAGRA. 483 

the hair or pull the hair through a cloth saturated with 
vinegar or dilute acetic acid, which will soften the glue-like 
substance of the nits. JSTo attention is to be paid to the 
dermatitis until after the cause of it is removed, when it 
will rapidly get well under any simple treatment. In 
private practice an infusion or tincture of delphinium 
staphisagria (larkspur seeds), or a 10 per cent, solution 
of carbolic acid, or a \ to 1 per cent, solution of 
bichloride of mercury, may be substituted for the petro- 
leum. The bichloride should not be used if there is 
much dermatitis. The ointment of the ammoniate of 
mercury is efficient, but, as a rule, an ointment should 
not be used on hairy parts. Blue ointment is a well- 
known remedy for pediculosis pubis, but it is apt to set 
up a denuatitis that is undesirable, and should not be 
prescribed. Sabouraud advises the use of equal parts of 
compound spirits of ether and xylol applied on absorbent 
cotton. He says it kills the lice and the nits instantane- 
ously so that they may be easily removed with a comb. 
For pediculosis vestimentorum there is no use in mak- 
ing any application to the skin. The woollen clothes 
should be baked in a hot oven, and the underclothing and 
sheets should be well boiled. If this cannot be done, or 
new clothes obtained, powdered sulphur or staphisagria 
may be powdered in all the seams of the clothing, and a 
5 per cent, ointment of carbolic acid applied to the body. 
Jamieson recommends smearing the whole body in all 
cases with vaseline and then giving a warm carbolic acid 
bath. 

Pelade. See Alopecia areata. 
Peliosis Eheumatica. See Purpura. 
Pelioma Typhosum. See Maculse cserulese. 

Pellagra. Synonyms : Risipola lombarcla ; Mai de la 
rosa ; Mai roxo ; Lombardian leprosy. 

Symptoms. But few cases of this disease have been 
reported in this country. Since the number of Italians 
is constantly increasing here it is important for us to be 



484 DISEASES OF THE SKIN. 

able to recognize the disease. It has prodromal symp- 
toms of progressive weakness, intestinal catarrh, lassitude, 
giddiness, headache, and burning sensations in the back, 
limbs, hands, and feet. These make their appearance in 
the spring, and, shortly after, an erythema affects the back 
of the hands down to the articulation of the first and 
second phalanges, the back of the wrists and forearms up 
to the elbow, the back of the feet, if the person goes 
barefoot, the front of the neck and chest to the lower 
edge of the first piece of the sternum, and, in women and 
children, the forehead, nose, and cheeks — that is, all those 
regions exposed to the sun. The color is bright, dark, 
or livid red, and is not a simple erythema, as the color 
cannot be made to disappear completely under pressure. 
The skin is often so swollen as to prevent all work. Bulla? 
may form upon the affected parts and be followed by 
erosions. In a few weeks desquamation begins, but the 
skin continues discolored and thickened up to July or 
August, when a gradual decline of all the symptoms 
takes place. During the winter the patient may appear 
quite well, but a relapse is pretty sure to occur duriug 
the next spring, and to recur each succeeding spring with 
ever-increasing severity of all the symptoms, and spread 
of the eruption ; the patient emaciates, loses strength, 
develops grave cerebro-spinal neuroses, sinks into a 
typhoid state, and dies. The skin becomes atrophied, 
smooth, shining, cracked, or it may be thickened. There 
is a loss of cutaneous sensibility, and the erythematous 
redness gradually extends over the whole surface of the 
body. The average duration of the disease is five years. 
Etiology. The disease is endemic in northern and 
central Italy, especially in Lombardy, Venetia, and 
iEmilia ; in the southwestern part of France, and in the 
northern part of Spain. It may occur anywhere. Women 
are most subject to it, children least so. It seems to be 
a disease fostered by poverty, want, and bad hygiene, and 
to be induced by an almost exclusive diet of decomposed 
or fermented maize, or, possibly, other grains. Some cases 



PEMPHIGUS. 485 

have been traced to the drinking of spirits made from 
damaged maize. It is, therefore, similar in origin to ergot- 
ism. It sometimes occurs in people living in bad hygienic 
conditions though not living on maize. It is not conta- 
gious or hereditary. 

Diagnosis. A suspicion of a case being one of pellagra 
should be aroused whenever an erythema upon the exposed 
parts is met with in a person coming from the regions in 
which the disease is known to be endemic, especially if it 
is combined with more or less lassitude and hebetude. 

Treatment. The treatment of the disease is mainly 
hygienic and symptomatic. Crocker has faith in the effi- 
cacy of arsenic for adults, and frictions with chloride of 
sodium solution in children. 

Pemphigus. Synonyms : Pompholyx ; (Ger.) Blasen- 
ausschlag ; (Ital.) Pemiigo. 

A chronic disease of the skin characterized by the 
eruption of successive crops of bullae upon the apparently 
sound skin and with either transient or no antecedent 
erythema. 

At one time every bullous eruption was a pemphigus, 
but with more careful observation and study a number of 
bullous eruptions have been established as distinct diseases. 
Many cases now included under dermatitis herpetiformis 
used to be regarded as pemphigus. It is probable that 
this process of elimination will continue. In the mean- 
time a considerable degree of uncertainty pervades our 
knowledge of the disease, both as to its symptomatology 
and etiology, and we can only stand and await further de- 
velopments. While in this attitude we must have some 
sort of a chart to guide us, and it has been my object to 
draw the lines of pemphigus with as great sharpness as 
possible. 

The disease is a rare one in this country, only 385 cases 
being reported in a total of 307,406 cases in the statistical 
tables of the American Dermatological Association from 
1877 to 1897. 



486 DISEASES OF THE SKIN. 

Symptoms. It is usual to describe two varieties of 
pemphigus, namely, pemphigus vulgaris and pemphigus 
foliaceus. Besides these we have pemphigus vegetans and 
pemphigus neonatorum. 

Pemphigus Vulgaris may begin with an outbreak of 
bullae, or there may be more or less constitutional disturb- 
ance before their appearance. The latter condition is 
more often seen in debilitated subjects, children, and old 
people, and consists in chilliness, nausea, and, perhaps, a 
rise of two or three degrees of temperature. These con- 
stitutional disturbances may recur before the appearance 
of each crop of bullae. The characteristic eruption is an 
outbreak of two or more up to a hundred or more pin- 
head- sized vesicles that in a few hours develop into tense, 
oval, hemispherical, prominently raised, fully distended 
bullae with translucent contents. The size of the bullae 
varies ; it may be but one-eighth of an inch in diameter, 
or by the coalescence of several neighboring bullae, large, 
irregular ones of two or three inches in diameter may be 
formed. One distinguishing feature of these bullae is 
that they have no areola, but spring up at once from the 
seemingly healthy skin. Their contents soon become tur- 
bid, or perhaps purulent, and then a slight inflammatory 
halo may form. Hemorrhage into the bullae rarely oc- 
curs. The bullae do not tend to rupture spontaneously, 
but to dry up, and leave the dried cover as a crust. If 
they are ruptured accidentally, an excoriated place is left 
that heals more or less readily, according to the general 
condition of the patient. Some pigmentation may be left 
for a time to mark the site of the bullae. 

This eruption may take place anywhere, but affects par- 
ticularly the lower part of the face, the trunk, and limbs. 
The region of the crotch is a favorite site. It is usually 
bilateral, and may be roughly symmetrical. Bullae may 
occur, in grave cases, in the mouth and throat. The life 
of the individual bulla is two to eight days ; but while 
one crop is disappearing a new one occurs, and the dura- 
tion of the disease may thus be measured by weeks or 



PEMPHIGUS. 487 

months. Sometimes there is an interval of weeks or 
months between the outbreaks. In favorable cases a few 
crops appear, and that is all, the patient making a good 
and complete recovery. In less favorable cases, or when 
the eruption is very extensive, frequent relapses and many 
excoriations take place, the patient's strength becomes 
exhausted by the constant drain upon his system and loss 
of rest on account of the discomfort of his condition ; he 
may die in a typhoid state, or of some intercurrent affec- 
tion. A number of cases of death from the disease within 
two or three weeks have been reported, and to these the 
name of acute pemphigus is given. A few authorities have 
reported acute bullous eruptions running their course in 
three to six weeks and ending in recovery as acute pem- 
phigus. Many of these cases were probably cases of 
bullous erythema, as in them a preceding erythema is 
noted in the reports of the cases. Most cases run a 
chronic course, extending over months or years. 

In rare instances a diphtheritic membrane may form at 
the site of the bulla, or, instead of healing taking place, 
a gangrenous process may be set up, with considerable 
destruction of tissue, or hemorrhage may take place in 
some of the bullae. 

All the mucous membranes may be affected by pemphi- 
gus, and the excoriations that thus form in the mouth add 
greatly to the discomfort of the patient. The conjunctiva 
is not spared,- and if attacked serious deformity results. 

Neumann has described as pemphigus vegetans a bullous 
eruption in which healing does not take place, but the 
base becomes covered with sprouting granulations and 
assumes an uneven surface marked by furrows and secret- 
ing a thin fluid. The raw patches thus formed spread 
slowly at their circumference, and neighboring ones coa- 
lesce. In women the first lesions are usually seen about 
the vulva, and from there the disease spreads over the 
genito-anal region. In all cases the regions affected are 
the axillae, the root of the neck, the hands and feet, crotch, 
elbows, and scalp. It never becomes universal. Pig- 



488 DISEASES OF THE SKIN. 

mentation in points often follows the drying up of a 
bullae. The disease proves progressive ; marasmus and, 
finally, death closes the scene. Most of the cases are in 
syphilitics. 

Cases of pemphigus neonatorum have been reported 
from time to time, and epidemics of it have been described. 
These are so evidently septic in origin that they hardly 
admit of being classified under the heading of pemphigus. 
Careful reading of not a few outbreaks of contagious 
pemphigus reported in the German journals will convince 
one who is acquainted with the bullous form of contagious 
impetigo that a mistake in diagnosis had been made by the 
reporter. Still, until further evidence is forthcoming, it is 
probably advisable to allow that both of these varieties of 
the disease do exist. Pemphigus pruriginosus is another 
variety made by writers. It fits in quite well under 
Duhring's dermatitis herpetiformis. 

Pemphigus Foliaceus differs considerably from pemphi- 
gus vulgaris. It may begin as such or it may develop 
from pemphigus vulgaris. Behrend 1 teaches that the 
difference between the two forms is simply a matter of 
coherence between the epidermis and corium, this being 
so slight in pemphigus foliaceus that we have a flaccid 
bulla instead of the tense, fully distended one of pemphi- 
gus vulgaris. 

Pemphigus foliaceus is the most rare variety of the dis- 
ease, Crocker giving its occurrence as one in five thous- 
and cases. It may present its peculiar features from the 
start, or begin as an ordinary pemphigus, or as a superfi- 
cial cutaneous oedema, or as dermatitis herpetiformis. 
Its characteristic lesions are flaccid bullae, with opaque 
contents, that soon rupture and leave raw, moist surfaces 
with an edge of ragged epithelium. The fluid of the 
bullae changes its position with the position of the patient, 
always seeking the most dependent part, and soon becomes 
purulent. After the disease has existed some time the 
patient emits a sickening odor on account of the large 
i Vierteljahr. f. Dermat. u. Syph., 1879, vi., 191. 



PEMPHIGUS. 489 

amount of raw surfaces of the ruptured bullae that are 
bathed with sero-pus. Affecting at first only a limited 
space, by degrees the disease spreads so that the whole 
body-surface becomes red and weeping, looking like 
eczema rubruin, with crusts and areas of ragged epithe- 
lium. The palms and soles are often spared on account 
of the thickness of their epidermal coverings. When the 
skin is thus generally involved, it is difficult to estab- 
lish the fact of the occurrence of new bullae. The mucous 
membranes of the mouth and pharynx are affected in like 
manner, becoming converted into raw patches. - The hair 
falls out ; the nails become thinner, brittle, atrophied, and, 
it may be, drop off; and ectropion is apt to result from 
the contraction of the skin about the eyes. 

The condition of the patient is most deplorable in these 
extensive cases : his skin is stiff and sore, and perhaps 
smarts ; and after months or years he succumbs to the 
drain on his system, sinks into a typhoid state, and dies. 
During the early part of the disease there may be no con- 
stitutional disturbance. But eventually death is quite 
sure to result, if not from the disease, from some intercur- 
rent affection against which the patient is unable to offer 
any resistance. 

Etiology. AYe know very little about the causes of 
pemphigus. The tropho-neurotic theory of the disease 
offers us a cloak for our ignorance, and perhaps is, after 
all, the true one. Experiments have demonstrated that 
bullae can be made to form by operations on the spinal 
cord, and observation has shown that bullae do form in 
certain spinal diseases. Both sexes are subject to the dis- 
ease. Children are more often affected than adults. The 
septic origin of certain bullous eruptions has already been 
spoken of under the heading of pemphigus neonatorum, 
and a number of cases of acute pemphigus occurring in 
butchers and in those engaged in handling meats have 
been reported by G. Pernet and W. Bullock. 1 All these 
ended fatally in a few days. Johnston believes that 

1 Brit. Journ. Dermat., 1896, viii., 157. 



490 DISEASES OF THE SKIN. 

the disease is caused by a toxin developed in the internal 
economy of the individual. Bullous eruptions are heredi- 
tary in some families, and in some subjects follow slight 
injuries to the skin. This is named Epidermolysis bul- 
losa, which see. Chilling of the body seems to have been 
the exciting cause of some cases. Most subjects of the 
disease are debilitated. Some have advanced the theory 
that an excess of ammonia in the blood or defective 
kidney-elimination is the cause of the disease. Attacks 
of the disease have been observed to occur with each 
new pregnancy in some women. 

Pathology. " Most authors regard the actual for- 
mation of the bulla as due to an inflammation of the papil- 
lary layer, with outpouring of fluid from the vessels ; but 
Auspitz calls it an akantholysis, or loosening of the 
prickle-cell layer, by the sudden escape of fluid from the 
vessels, destroying the young prickle-cells and lifting up 
the epidermis as a whole. Any inflammatory phenomena, 
he thinks, are secondary." (Crocker.) G. Grinew 1 has 
found in pemphigus foliaceus that the red blood corpus- 
cles are decreased, while the white are slightly increased. 
The size of the blood cells is decreased so that the blood 
is watery. Haemoglobin is decreased as is the specific 
gravity of the blood. The number of lymphocytes is les- 
sened, while the leucocytes and eosinophyl cells are in- 
creased. Microorganisms have been found in the fluid 
both of the bullae of chronic and acute pemphigus, and 
a peculiar diplococcus has been demonstrated by several 
observers in apparent causal relation to the disease. 

Diagnosis. If we regard the pathognomonic symp- 
toms of pemphigus vulgaris as fully distended bullae 
springing up out of the sound skin without any antece- 
dent erythema and without inflammatory halo, and occur- 
ring in crops so as to run a chronic course, then little 
difficulty will arise in diagnosis. A bullous erythema has 
bullae arising upon an erythematous base or with erythe- 
matous lesions elsewhere, and runs a comparatively acute 
i Dermat. Zeit., 1904, xi., 888. 



PEMPHIGUS. 491 

course. Dermatitis herpetiformis differs from pemphigus 
iu the grouping and multiformity of its lesions, and the 
great amount of itching that attends it. No matter how 
long it has lasted, it is seldom accompanied by the constitu- 
tional disturbances that are met with in pemphigus chron- 
icus. In bullous urticaria the bulla rises upon a wheal. 
The bullous form of impetigo contagiosa will be quite sure 
to present the characteristic impetigo pustules upon the 
hands or face, and search will probably discover some 
child with impetigo with whom the patient has come in 
contact. Varicella bullosa occurs epidemically, and runs 
a short course. 

Pemphigus foliaceus when in its early stage, and affect- 
ing but a small area, is readily diagnosed by the occur- 
rence of its flabby bullae, arising without antecedent in- 
jury. After it has lasted long enough to involve a large 
area it is with difficulty differentiated from eczema rubrum 
and dermatitis exfoliativa. In fact, without the history 
of the case it is sometimes almost impossible to make the 
diagnosis. It may be differentiated from eczema rubrum 
by its crusts being made less of dried exudation than of 
epithelium, by the slighter amount of exudation, by the 
ragged look of some part of the disease, and by careful 
watching for and finding the large flaccid bullae which 
will be sure to appear if the case is one of pemphigus. 
Moreover, in universal eczema rubrum the itching is 
more pronounced. Dermatitis exfoliativa differs from 
pemphigus in the absence of moisture and of bullae, and 
in the thinness of the exfoliated epidermis. Lichen ruber 
acuminatus is perfectly dry and presents characteristic 
papules. 

Treatment. The drug upon which most reliance is 
placed in the treatment of this disease is arsenic. We 
may use Fowler's solution ; or arsenious acid in pill-form, 
as the tablet triturate with piperina, or the Asiatic pill. 
Whatever form is given, it is advisable to begin with 
small doses and gradually increase them until the limit of 
tolerance is reached or the disease is controlled. Unfor- 



492 DISEASES OF THE SKIN. 

tunately it often disappoints us in its effects. Crocker 
regards salicin as almost as valuable as arsenic, given in 
doses of 15 grains three times a day and increased to 
double that amount. Attention to diet and hygiene, and 
the general condition of the patient, with the judicious 
use of tonics, such as quinine, iron, strychnin and cod- 
liver oil, will often do as much, if not more, than arsenic 
to cure the patient. 

Locally, dusting powders of oxide of zinc, starch, ly- 
copodium, or bismuth in varying combinations ; lotions 
of lime-water, borax, zinc, liquor plumbi subacetatis, and 
the like, prove helpful in allaying irritation and discom- 
fort. Lassar's paste is also a good application. Unna 1 
recommends equal parts of linseed oil, lime-water, oxide 
of zinc, and chalk, both to dry up the bullae and prevent 
their return. Linimentum calcis with 1 minim of creo- 
sote to the ounce is recommended by Hardaway. The 
continuous warm bath has afforded great relief in the 
Vienna hospitals. The bullae may be opened if they are 
troublesome. Alkaline and antiseptic mouth- washes will 
afford relief where the mucous membranes are affected. 

Prognosis. The chances of recovery are uncertain. 
While many cases of pemphigus vulgaris recover, re- 
lapses are the rule, and if the patient is not strong, or the 
disease has lasted a long time, a guarded prognosis should 
be made. Hemorrhagic, diphtheritic, or fungating bullae 
are of bad augury. Pemphigus vegetans, pemphigus 
foliaceus, and pemphigus acutus arising from infection are 
almost invariably fatal. 

Pemphigus Acutus Contagiosus. See Impetigo con- 
tagiosa. 

Pemphigus Gangraenosus. See Dermatitis gangrenosa 
infantum. 

Perforating Ulcer of the Foot is an accident liable to 
occur in those in whom the nerve-supply of the foot is 
deficient, as in locomotor ataxia, syphilis, leprosy, and 

i Monatshefte f. prakt. Dermat., 1888, vii., 108. 



PERIADENITIS SUDORIPARA. 493 

peripheral neuritis. The most common location for the 
ulcer is at the metatarso-phalangeal articulation of the 
great or little toe, or the cushion of the great toe. It 
may be only on one foot, or both feet may be aifected. 
The process is slow, beginning as a proliferation of the 
epidermis like a corn, under which suppuration takes 
place, and an ulcer is left. This goes deeper into the 
tissues, until a sinus forms that reaches to the bone. The 
edges of the ulcer are hard. The external opening is 
often smaller than the sinus below. Usually there is 
little pain, though there may be hyperesthesia of the sur- 
rounding parts, and attacks of inflammation at times. 
This painlessness distinguishes it from a suppurating 
corn. The palms may be affected in the same way as the 
soles. The disease is very intractable, and must be man- 
aged on surgical principles, amputation of the whole or 
part of the foot being required in some cases. Death 
may result from the disease. 

Under the name of Hand and Foot Disease Hyde 
reported * three cases of ulcerations of the hands and feet 
that he regarded as due to tropho-neurotic disturbances. 
In these cases, with or without functional disturbances, 
such as hyperidrosis and coldness of the hands and feet, 
bromidrosis, local anaesthesia, vertigo, faintness, and rheu- 
matic pains, there were found various grades of dystro- 
phia unguium, from roughness to onychogryphosis, ten- 
der and painful or insensitive maculations of the hands 
and feet, pigmentary patches on the palms and soles or 
the back of the hands or feet, or both ; different derma- 
toses, such as erythema, eczema, ichthyosis, local alo- 
pecias, hypertrichosis, symmetrical tylosis, with or without 
spontaneous exfoliation or recurrence. After a time ul- 
cerations formed on the hands or feet, or on both hands 
and feet. 

Periadenitis Sudoripara. See Abscess of sweet glands, 
i Phila. Med, News, 1887, li., 416. 



494 DISEASES OF THE SKIN. 

Perifolliculitis Suppurees et Conglomeres en Placards. 
Under this lengthy title Leloir l has described and figured 
a rare disease of the skin which specially affects the back 
of the hands. 

Symptoms. It seems to commence as a diffused red 
patch upon which develop small pustules, which itch 
slightly; or as small, red, more or less conglomerate, 
slightly itching elevations that form patches. The patches, 
however formed, are sharply defined, raised from two to 
five millimeters, round or oval, flattened, and of red, 
vinous, violaceous, or blue color. They vary in size from 
that of a ten-cent piece to that of a silver dollar, and are 
often crusted. When the crust is removed, the exposed 
surface is smooth or mammillated, but never papilloma- 
tous ; and riddled with a number of pin-point- to pin- 
head-sized openings, corresponding to glandular orifices, 
many of which are closed with a plug of greenish, dried 
pus. Beside these openings there are a number of green- 
ish points that are ready to become such whenever the 
epidermis over them is removed. At a more advanced 
stage the openings form small pinhead-sized ulcers. By 
compression of the patch these openings give vent either 
to a drop of pus or serous fluid, or little, elongated, vermi- 
celli-like whitish masses. In still more advanced cases 
the patches become more elevated, fluctuation manifests 
itself, and sero-pus may be expressed. The patches are 
usually single, but may be multiple. The back of the 
hand and wrist are the usual locations of the disease ; but 
it may occur upon the dorsum of the foot or the outer 
side of the thigh, or be disseminated, but chiefly located 
on the extremities. The course of the disease is acute. 
It is fully developed in eight days ; it then continues a 
week or two and disappears in about twelve days more. 
If badly treated, it may last longer, and be followed by 
a papillary condition. It is unattended by subjective 
symptoms, except slight itching. It leaves either no 

1 Ann. de derm, et de syph., 1884, v., 437. 



PERLECHE. 495 

trace of itself, or a delicate superficial cicatrix that dis- 
appears, or a slight staining that soon fades. The hair 
is unaffected, though the disease may involve its fol- 
licles. 

Pathology. The disease is a purulent inflammation 
of the skin follicles, specially of the lanugo hairs, and the 
pilo-sebaceous follicles of regions deficient in true hairs. 
It is possibly microbic in origin. Crocker regards it as 
a form of ringworm. 

Diagnosis. The disease is diagnosed from trichophy- 
tosis by its more rapid course, and recovery under sim- 
ple treatment ; by the hair being unaffected ; and by the 
absence of the trichophyton in the hair. Anthrax differs 
from it in the more pronounced character of its local and 
general reaction, its central core, -and inflammatory indu- 
ration. Tuberculosis verrucosa cutis is much slower in its 
evolution, is serpiginous, and does not yield to simple 
treatment. Eczema differs from it in not having such 
sharply marked borders ; in wanting the characteristic 
openings and livid tint ; and in having more pronounced 
itching, a mucous, sticky discharge, and a comparatively 
long duration. 

Treatment. The treatment is simple and consists in 
squeezing out the pus once a day, bathing the part for 
half an hour in warm carbolized water or a solution of 
boric acid, and covering with an antiseptic dressing. If 
papillse have formed, they should be scraped off, and the 
surface touched with nitrate of silver. In some obsti- 
nate cases it may be necessary to scrape out the whole 
patch. 

Perionyxis. See Paronychia. 

Perleche. According to Brocq, this is a disease occur- 
ring in infants and affecting the commissures of the lips. 
Their epithelium is pale, macerated, desquamating, while 
the skin underneath is red and slightly inflamed. Some- 
times fissures will form that are painful, and may bleed 
when the patient widely opens his mouth. The inflam- 



496 DISEASES OF THE SKIN. 

mation may spread to the neighboring regions. It runs 
a course of two or three weeks, but is subject to relapse. 
It is contagious, and is due to a streptococcus. 

It bears a close resemblance to the fissures of the lip 
met with in syphilis, but is marked by an absence of all 
other symptoms of syphilis, 

The treatment consists in touching the diseased parts 
with sulphate of copper or alum, or an antiseptic solution, 
and in carefully looking after the nursing-bottles. 

Pernio. See Dermatitis calorica. 
Pfimdnase. See Hypertrophic rosacea. 

Phagmesis. A rare condition in which it is said that 
feathers instead of hair adorn the body. 

Phtheiriasis. See Pediculosis. 

Pian. See Yaws. 

Pian Ruboide. See Dermatitis papillaris capillitii. 

Piebald Skin. See Leucoderma. 

Piedra. Synonyms : Tinea nodosa ; Trichomycosis 
nodosa. 

Symptoms. This disease, or deformity of the hair, is 
said to occur only in Cauca, one of the United States of 
Colombia, and was first described in 1874 by Dr. N. 
Osorio, of the University of Bogota, but may occur else- 
where. It consists in the occurrence along the shaft of 
the hair of from one to ten small dark-colored nodes 
which are very hard and gritty, and rattle like stones 
when the hair is combed or shaken. The stony hardness 
of the nodes gave the disease its name " Piedra," which 
is the Spanish for " stone." These nodes are always 
placed at irregular intervals along the hair-shaft, begin- 
ning at about half an inch from the point of exit of the 
hair, the root being unaffected. The disease occurs most 
commonly in women, men being rarely affected, and it is 
the head-hair alone which exhibits these nodes. The dis- 
ease is non-contagious, and is met with only in warm 
valleys. 



PINT A. 497 

Etiology. Dr. Osorio thought that the nodes were 
produced by an agglomeration of epithelium in certain 
parts of the hair. Mr. Morris * believes it is due to the 
use of a peculiar mucilaginous linseed-like oil, which is 
used particularly by the native women to keep their hair 
smooth and shiny. Another theory is that it is due to 
the use of the water of certain stagnant rivers which is 
very mucilaginous. Heat seems essential for its produc- 
tion, as the employment of either of these fluids will not 
cause the disease in cold climates. 

Microscopical examination of the affected hair shows 
that the nodes consist of a honeycombed mass of pig- 
mented spore-like bodies, the whole mass arising from 
one cell which seuds out spore-like columns radially in 
all directions. As soon as the cells have reached a cer- 
tain size they seem to alter their shape, become darker in 
color, and form a pseudo-epidermis. It is, therefore, a 
fungous growth. The nodes were found to be very hard 
to cut, and when considerable force was used they broke. 

Diagnosis. Piedra differs from trichorrhexis nodosa 
in the stony hardness of the nodes, in its occurring prin- 
cipally upon the head-hair, in its probable etiology, and 
in the microscopical appearances it presents. 

Treatment. By the use of hot water the nodes can 
be entirely removed. 

Pigmentary Mole. See Nsevus pigmentosus. 
Pigmentgeschwiilst. See Melanotic sarcoma. 
Pigmentkrebs. See Sarcoma. 
Pigmentmal. See Nsevus pigmentosus. 
Pimples. See Acne. 

Pinta. Synonyms : Mai de los pintos ; Tinna ; Caraate 
or cute ; Quirica ; Spotted sickness. 

This disease occurs in the Philippines, southern Mexico, 
Panama, and South America. 

Symptoms. According to Crocker, from whose work 

1 Lancet, 1879, v., 407., 



498 DISEASES OF THE SKIN. 

this account is drawn, it consists of scaly spots varying in 
color, shape, number, and size. They show themselves 
first on the uncovered parts, but may affect any and all of 
the cutaneous surface. The disease spreads by the periph- 
eral extension of old patches and the formation of new 
ones. The patches are round or irregular in shape, 
sharply or ill-defined, and of black, gray, blue, red, or 
dull- white color. The red and white patches are deeper- 
seated than the others, being located in the rete and corium. 
The patches may be of uniform color, or of different 
tint, but do not change their color after they have once 
formed. They are scaly and usually feel rough and dry. 
The hair grows gray and falls. There is some itching, 
and a bad odor emanates from the patient. The course 
of the disease is chronic and shows no tendency to 
recovery. 

Etiology. The disease is contagious, and its spread is 
favored by dirt and neglect. It is most common in the 
poor natives of Indian stock. It is of fungous origin, 
and, in fact, seems to be allied to chromophytosis. 

Treatment. The treatment is the same as for chro- 
mophytosis. 

Pityriasis Alba Atrophicans. This disease begins in 
early life as a partly lamellar, partly branny desquama- 
tion of the skin without redness or any other form of 
efflorescence. The skin may be affected wholly or in 
part. After lasting ten to fifteen years it is followed by 
secondary atrophy of the skin, which becomes thinner, 
and softer. The subcutaneous fat is lost and the veins 
show through. 

Pityriasis Lichenoides Chronica. This is the name given 
by F. Juliusberg * to a disease described by Neisser as 
Lichenoid and psoriasiform exanthem, and by Judassohn 
as Dermatitis psoriasiformis nodidaris. E. Biecke 2 re- 
gards it as the same as parakeratosis variegata. It af- 

1 Arch. f. Dermat. u. Syph.,1899, 1., 359. 

2 Arch. Dermat. et syph., 1907, liii., 51 et seq. 



PITYRIASIS ROSEA. 499 

fects men more than women, and is seen most often be- 
tween the fifteenth and twentieth years of age. It 
consists in a polymorphic eruption, which may occur any- 
where on the body, though the scalp and face are nearly 
always free. It begins as bright red, pinhead-sized, flat, 
smooth papules, surrounded by a hypersemic zone that 
soon fades. These flatten and broaden out into lentil or 
larger sized papules, which may be round, oval, or 
angular in shape, and are sharply defined. Some are 
scarcely raised above the skin level. They are then of 
dull, red color, or pale or dark brown, with silvery- white, 
shining, delicate scales, resembling the scales of psoriasis. 
Sometimes the lesions coalesce to form rings, serpiginous 
figures, rows, or stripes. There may be vesicles and 
crusts here and there. The eruption becomes better and 
worse, and is not amenable to treatment. It is a para- 
keratosis with superficial inflammatory infiltration in the 
corium and papilla?. 

Pityriasis Maculata et Circinata. See Pityriasis rosea. 
Pityriasis Nigricans. See Chromidrosis. 
Pityriasis Parasitaire. See Chromophytosis. 
Pityriasis Pilaris. See Keratosis pilaris. 

Pityriasis Rosea. Synonyms : Pityriasis maculata et 
circinata ; Herpes tonsurans maculosus (Hebra) ; Roseola 
pityriaca (Barduzzi); Pityriasis circine et margine (Vidal); 
Pityriasis ros£e (Gibert); Ery theme papuleux desquamatif. 

An acute disease of the skin characterized by an erup- 
tion of rosy-red macules that enlarge into dry, scaly, oval 
or annular patches with rosy-red peripheries and chamois- 
yellow, wrinkled centres ; it runs a definite course and 
terminates in recovery. 

Symptoms. The outbreak of the disease may be pre- 
ceded by slight constitutional disturbances, such as ma- 
laise, loss of appetite, and headache, with a slight rise of 
temperature just before the outbreak of the eruption* 
Crocker says that there is often enlargement of the post- 
sterno-mastoid and submaxillary glands, and maybe other 



500 



DISEASES OF THE SKIN. 



glands. The eruption itself most often begins without 
prodromata upon the upper part of the chest, a little above 
the breasts, or, according to Brocq, 1 at the level of the 
waistband, anteriorly and a little to one side, where he 
locates what he calls the " primitive patch. " The prim- 
ary lesions are miliary or small papules of pale-red color, 
surrounded by an erythematous zone. These soon en- 
large into rosy-red, slightly raised macules, and slowly 
increase peripherally into oval or rounded patches with 



Fig. 68. 




Pityriasis rosea. By the courtesy of Dr. S. I. Rainforth. 

well-defined borders raised somewhat higher than the 
centres. When the patches have attained a diameter of 
half an inch or more the centres begin to clear up by be- 
coming of a yellow, old-parchment color, scaly and shiny, 
while the border is pale red. Later the centre may dis- 
appear and rings only remain ; or if two or more patches 
meet at their borders, irregular gyrate figures may be 
formed. All the lesions do not attain the same degree 
of development, and in well-developed cases lesions in all 
stages will be found. The lesions are slightly scaly from 

1 Ann. de derm, et de syph., 1887, viii., 615. 



PITYRIASIS ROSEA. 501 

the commencement, and the furfuraceous desquamation 
continues until the faint mark left by the lesion disappears. 
Itching, usually slight in amount and only when the per- 
son is warm, is the only subjective symptom. Some- 
times it is severe. The eruption is most marked upon 
the neck, infra- and supra- clavicular regions, sides of the 
chest, and shoulders ; it may be marked also on the ab- 
domen and buttocks. The whole body may be involved, 
but the hands and feet are usually spared, and it is un- 
common on the face. After some three to six weeks the 
disease tends to spontaneous recovery, although it may 
last for months. 

Etiology. We know nothing about the cause of the 
disease. It affects all ages and both sexes. Crocker 
finds that one-third of the cases are in children. Most 
of the cases I have seen have been in young adults. This 
difference may be accounted for by the fact that he Las a 
large children's dispensary service. Some cases seem to 
be due to overheating of the skin by wearing too heavy 
underclothing. Hyde and Montgomery, teach that it re- 
curs most often in blond subjects who have been enfee- 
bled by great physical fatigue or over-study in school. 
The disease seems to occur epidemically in some in- 
stances, and cases are apt to present themselves in groups. 
Contagion has not been established. Bazin regards it as 
arthritic. It may be parasitic, but as yet the parasite 
awaits demonstration. Vidal * describes a parasite that 
he names the microsporon anomoeon, as found m pity- 
riasis circine" et margin^, which is the same disease. 
Hebra regarded it as a manifestation of trichophytosis, 
and some authorities still think that some cases are 
diffused ringworm. There is a strong probability 
that it is due to a toxin developing in the intestinal 
tract. 

Pathology. The process is a mild inflammation in 
the upper cutis, more marked toward the periphery of 
the lesions. In the more pronounced cases minute vesi- 
1 Ann. de derm, et de syph., 1882, iii., 22. 



502 DISEASES OF THE SKIN. 

cles, visible only microscopically, are found beneath the 
corneous layer. 

Diagnosis. Pityriasis rosea must be differentiated 
from the early circinate, scaling, macular syphiloderm ; an- 
nular psoriasis ; seborrheal dermatitis ; and disseminated 
trichophytosis. The one most distinguishing feature of 
pityriasis rosea is the wrinkled old-parchment yellow of 
the centre of the ring. This is absent from the lesions of 
all the other diseases with which it is likely to be con- 
founded. The syphilide is of a less bright-red color, and 
there surely will be some other evidence of syphilis to 
guide us. Psoriasis is far more scaly ; the scales are of 
a white color ; the tips of the elbows and the anterior 
face of the knees will be specially affected ; and typical 
psoriatic patches will be found somewhere. Seborrheal 
eczema occurs upon the middle sternal and interscapular 
regions particularly ; the patches have a greasy feel ; the 
scales are thicker than in pityriasis rosea ; the papular 
lesions are more raised and evidently in relation to a fol- 
licle of the skin ; and the lesions show little tendency to 
spontaneous involution. Cases occur in which it is very 
d ifficult to make the diagnosis between this and pityriasis 
rosea. In trichophytosis the fungus is readily found un- 
der the microscope, which is a decisive test. Apart from 
that, ringworm does not spread so rapidly nor involve 
such wide areas. Measles differs from it by having ca- 
tarrhal and constitutional symptoms, and by the absence 
of the rings with old-parchment-like centres. 

Treatment. Pityriasis rosea is a self-limited dis- 
ease, and recovery is sure to take place in a short 
space of time, usually from three to six weeks. Though 
treatment seems not to have any marked effect on the 
disease, we may use lotions of salicylic acid, 10 to 20 
grains to the ounce, or of boric acid ; or content our- 
selves by allaying the itching with lotions of carbolic 
acid (10 grains to the ounce), calamine, oxide of zinc, 
and the like. Tepid alkaline or bran baths may be 
used, followed by a dusting powder. Crocker has 



PITYRIASIS RUBRA PILARIS. 503 

faith in salicin in the dosage of 15 grains three times a 
day. 

Pityriasis Rubra. See Dermatitis exfoliativa. 

Pityriasis Rubra Pilaris. This disease was first de- 
scribed by the French writers. 

It has been confused with lichen pilaris, psoriasis, lichen 
ruber and lichen planus, and pityriasis rubra. Several 
cases of lichen ruber reported in this country have been 
declared by the French to be cases of the disease under 
consideration, as well as the lichen psoriasis of Hutchin- 
son. Kaposi regards it as the same as lichen ruber. It 
is probable that the two are identical. 

Symptoms. A typical case has three principal ele- 
ments : 1. Asperities of the follicular orifices ; 2. Desqua- 
mation ; 3. Roughness of the skin with exaggeration of 
its folds. The disease generally begins suddenly, without 
prodroma, but there may be some malaise, nervousness, 
insomnia, hyperesthesia of the finger-ends, formication, 
and the like. These prodromata are of short duration, 
and rarely cause the patient to go to bed. The uncovered 
parts are usually first affected with the eruption, but it 
may appear primarily upon the trunk or extremities. The 
initial lesion may be a simple exfoliation ; an erythema ; 
a scaling erythema ; a fine but scanty furfuraceous des- 
quamation ; a shiny redness with pityriasis ; desquamation 
of nail-bed, or fragility of nail. However beginning, the 
more pronounced form appears in a certain number of 
days or weeks, and may develop or abort at any point, or 
be limited to any region, or involve the whole body. 
When fully developed, a patch or the whole skin, as the 
case may be, presents the following characteristics : It is 
covered with elevations that are generally conical, but may 
present great diversity of shape. They may be discrete 
or coalesce. They may be so small as to be seen only by 
the aid of a microscope, or elevated many millimeters 
above the surface, with corresponding diameter. They 
are scaly, and vary in color from a silver white or gray to 



504 DISEASES OF THE SKIN. 

a bright or opaque red, red brown, or rosy yellow. Their 
summits may be flat, uneven, cone-shaped, or truncated, 
giving issue to a hair broken off at a little distance above 
the surface of the skin, and, it may be, sheathed by a cor- 
neous or sebaceo-squamous case. Instead of a hair pro- 
truding, it may form only a small comedo-like spot at the 
centre of the summit, or it may be wanting, or it may seem 
to exist alone, giving to the region the appearance of a 
badly shaven beard. Sometimes the cone presents a crater, 
at the bottom of which is a black point, a punctured 
scaly plate, or a psoriatic point. Patches are formed by 
the coalescence of the papules. They are fairly well de- 
fined, of all shapes, scaly, grayish in color, rough to the 
touch, and bear a resemblance to chagrin leather. Scat- 
tered about the usual papules will be found. The patches 
are very capricious, coming and going. The skin is scaly, 
dry, hard, rough like a file, and presents a " goose-skin " 
appearance. The scales may be scraped off without any 
loss of blood. 

The disease is generally symmetrical, but the lesions 
may be disseminated without order, or in irregular lines, 
groups, or islands, or may unite in tessellated areas. 
The cone-like elevations do not occur on the scalp, and 
are rare on the soles and palms. In these locations 
the disease takes the form of abundant desquamation upon 
a reddened base. When the face is attacked the skin is 
dry, red, scaly and thickened. All other regions may be 
affected, the cones forming about the follicles of the skin, 
especially about the hair follicles. The back of the phal- 
anges of the fingers are nearly always affected, appearing 
rough, uneven, and covered with patches of characteristic 
papules. This appearance of the back of the phalanges 
is one diagnostic mark of the disease. A favorite site is 
the upper part of the internatal furrow. Some variations 
from the type are encountered in different regions, but 
characteristic types will be found somewhere on the body. 
The hair may fall, and the nails may be deformed, opaque, 
and raised by an accumulation of scales under them. 



PITYRIASIS RUBRA. 505 

The general condition is unaltered, and little, if any, dis- 
comfort is experienced. The duration of the disease is 
indefinite, and relapses are the rule. Second and sub- 
sequent attacks may be shorter than the first. 

Etiology. The etiology of the disease is obscure. It 
is rarely met with. It occurs at all ages, and in both 
sexes, but most often in infancy or youth, and in males. 
Many causes have been assigned to it, such as cold, ex- 
cesses, rheumatism ; but none of these can be definitely 
said to be the cause. 

Pathology. The essential change is a hyperkeratosis, 
in the epithelial lining of the orifice of the hair follicle. 
All the layers of the epidermis are much thickened. Sec- 
ondary inflammation occurs in the upper derma. 

Diagnosis. The disease is to be diagnosed from ichthy- 
osis in not being congenital ; in attacking by preference 
the joints, scalp, face, and neck ; and in its spontaneous 
recovery for a time. From dermatitis exfoliativa by its 
benign course ; its location about the follicular openings ; 
and by the thick scaling of the palms and soles. From 
lichen ruber the diagnosis is difficult, the two being con- 
sidered by many as identical. H. Hebra has made a 
careful study of the two diseases, 1 and we give here his 
table of differential diagnosis between them : 

Pityriasis Rubra Pilaris. Lichen Ruber Acuminatus. 

1. Develops in the epidermis. 1. Develops in the cutis. 

2. Efflorescences bear scales from 2. From the beginning they are 

beginning, and often consist smooth and glistening. Scales 

of accumulations of epidermic form only late in the disease, 

scales alone, which can read- 
ily be scratched off. 

3. Efflorescences limited to folli- 3. Are not limited to the follicle 

cle mouths, especially those mouths, 

of bair follicles. 

4. Extensor surfaces of the ex- 4. Flexor surfaces more affected 

tremities especially affected. than extensor surfaces. 

5. Microscopically consists of 5. Marked collections of round 

thickening of the epidermis, cells in the papillary layers of 

with lengthening of the inter- the corium. 

papillary projections of the 

rete mucosum in certain 

places. 

6. Color of efflorescences scarcely 6. From beginning a bright red, 

differs from that of the skin becoming darker, and may 

at the beginning. Afterward change to deep rusty brown, 

becomes rosy or brownish red 
from consecutive hyperemia. 

iMonatshefto f. prakt. Dermat., 1889, x., 101. 



506 DISEASES OF THE SKIN. 

7. Roughness of the extensor sur- 7. Everywhere thickening and 

faces of the extremities, and roughness of the skin, in- 
satin-like smoothness on the creasing with the age of the 
trunk, with fine scales. disease. 

8. No accompanying subjective 8. Unbearable itching, great 

symptoms. burning, restlessness, and 

jerking movements of the 
limbs. 

9. No implication of the general 9. Fever, oedema (especially of 

health. lower extremities), albumin- 

uria, sleeplessness, general 
prostration, and loss of 
weight. 

10. Spontaneous r e c o v e r y , or 10. Often ends in death, always at- 

chronicity without danger to tended with marasmus, 

the patient. 

11. Cured by purely local means, 11. Cured, if at all, by constitu- 

though often obstinate. tional treatment, as with ar- 

senic. Unna's ointment of 
mercury and carbolic acid 
good. 

12. Little or no pigmentation left. 12. Deep-brown, even blackish- 

brown, pigmentation left 
which may last for months. 

13. Does not affect the mucous 13. Affects mucous membranes, 

membranes. especially of mouth and 

vagina. 

Psoriasis at times bears a strong resemblance to pityria- 
sis rubra pilaris, but it seeks the elbows and knees par- 
ticularly ; its scale is larger ; and it is not a follicular 
disease, never presenting comedo-like plugs, broken off 
hairs, or little elevations. 

Treatment. No satisfactory treatment has been found, 
but the remedies applicable to psoriasis or to ichthyosis 
can be used with advantage. Like in that disease, an 
attack may be overcome, but no assurance can be given 
against a relapse. Thus far no fatal case has been reported. 

Pityriasis Simplex. This form of scaling of the skin is 
most often seen on the scalp, where it is spoken of as 
pityriasis capitis, and constitutes that form of dandruff 
in which there is a more or less abundant scaling of the 
scalp. The hair is dry and unmanageable, and the head 
itches, especially when the patient sits under a light or 
becomes overheated. The patient is annoyed by the con- 
stant falling of the scales upon his clothing, and if the 
disease is very pronounced, brushing of the hair causes a 
small snowstorm of white, light scales. The scalp usually 
looks pale, and will be found covered with fine, grayish 
or yellowish, readily detachable scales. Sometimes there 



PLTCA POLONICA. 507 

are more or less redness of the scalp and a seam of red- 
ness along the forehead. The eyebrows, bearded portion 
of the face, pubes, and other regions may be aiFected. 
After an indefinite time alopecia is apt to follow a pity- 
riasis. This disease is the slightest grade of seborrheal 
dermatitis, which see. 

Pityriasis Tabescentium is that condition occurring in 
marasmic individuals where there is scaling of the whole 
skin specially marked on the extensor surfaces of the ex- 
tremities and trunk. 

Pityriasis Versicolor. See Chromophytosis. 
Plaques des Fumeurs. See Leucoplakia, 

Plica Polonica. Synonyms : Trichosis plica ; Trichoma ; 
(Pol.) Koltun ; (Ger.) Weichselzopf ; (Fr.) Plique polo- 
naise ; Polish ringworm. 

Symptoms. This is rather a condition than a disease, 
in which the hair of the head and other parts becomes 
matted together into variously shaped masses, on which 
rest all sorts of extraneous matters deposited from the 
air ; and in which are harbored vast hordes of pediculi. 
Sometimes these matted tresses are near the scalp, and 
sometimes far away. Not infrequently an oozing eczema 
of the scalp will be found. The masses will assume all 
sorts of shapes, to which various names have been applied. 
An offensive odor often emanates from the scalp. Occur- 
ring among ignorant people, as is usually the case, these 
plicas are regarded with superstition. The patient and 
friends refuse to have them cut off lest some dire disease 
befall the bearer. 

Under the name of Plica Neuropathica a few cases of 
matting of the hair into masses like those in plica polonica 
have been reported as occurring in cleanly individuals. 

Etiology. The cause of the condition is want of 
cleanliness combined with an oozing dermatitis of the 
scalp due to pediculi or any other cause. Plica neuro- 
pathica seems to be due to a peculiarity of the hair caus- 
ing it to felt. 



508 DISEASES OF THE SKIN. 

Treatment. The treatment consists in the liberal use 
of soap and water, and curing the dermatitis. If allowed, 
the speediest way of beginning treatment is to cut off the 
hair. The patient must be instructed in the hygiene of 
the scalp. 

Podelcoma. See Fungous foot of India. 
Poils Accidentels. See Hypertrichosis. 
Polytrichia. See Hypertrichosis. 
Polyidrosis. See Hyperidrosis. 
Polypapilloma Tropicum. See Yaws. 

Pompholyx. Synonyms : Dysidrosis; Cheiro-pompholyx. 

This disease was first described by Tilbury Fox and 
Jonathan Hutchinson from the same case, though inde- 
pendently of each other. The former thought that it was 
due to distention of the sweat glands, and named it dysi- 
drosis, while the latter named it cheiro-pompholyx from 
the bullous character of the eruption and its occurrence 
upon the hands. As it occurs upon the feet as well as 
the hands, Hutchinson's name is a misnomer. 

Symptoms-. The first thing that the patient notices is 
a burning and itching of the palms or soles, and sides of 
the fingers or toes. In a few hours small, clear, sago-grain- 
like vesicles, sometimes grouped, and with an erythema- 
tous zone about them, appear in these locations. They 
are often very numerous, and some of them run together 
to form small and large bullae. Their contents are at 
first clear and neutral ; later they become turbid and have 
an alkaline reaction. These vesicles do not tend to spon- 
taneous rupture. In a few days they dry up, their 
covers fall, and large and small, dry, red surfaces are left 
to mark their locations. If the lesions have been very 
numerous, the whole of the old skin may be shed. In 
slight cases the palms or soles will be dotted over with 
irregularly shaped red spots with ragged edges. As a rule, 
the back of the hands and feet are unaffected, though the 
rule has many exceptions. It is usually symmetrical or 
bilateral. Abortive attacks are .quite common in which 



POMPHOLYX. 509 

the disease is limited to two or three lesions on the side 
of one or more fingers. The subjective symptom is burn- 
ing, though itching may occur. The patients are seldom 
in perfect health, and are usually nervously depressed. 
Hyperidrosis of the aifected parts commonly accompanies 
or precedes the outbreak, and sometimes a lichen tropicus 
will be found on the trunk. The duration of the attack 
varies from a few days to three or four weeks, and re- 
lapses in the same or following years are common. Most 
all cases are seen in the summer. It is usually symmet- 
rical, though one side may be affected before the other. 
Some systematic writers regard the disease as an eczema. 

Etiology. Over the causes of the diseases there has 
been and still is active discussion. It seems to be in some 
way connected with the sweat glands, but whether it is a 
simple impediment to the escape of the sweat or an in- 
flammatory disease is not determined. Some able path- 
ologists ally the disease to herpes, and deny any connec- 
tion with the sweat glands. The occurrence of the dis- 
ease in hot weather points to the sweat apparatus as the 
organ at fault. There is probably a vasomotor neurosis 
at the bottom of the trouble. It affects all ages and both 
sexes, though most common in young adult women, and 
in those who are of nervous temperament or the subjects 
of worry and over-fatigue. It is said that organic or 
functional heart disease is the cause of some cases. Unna 
states that he has found constantly a bacillus in sections 
of the vesicles. 

Pathology. Robinson, who has carefully studied this 
disease, regards it as a neurosis allied to herpes and 
pemphigus. He thinks it has nothing to do with the 
sweat glands, but that it is inflammatory. The contents 
of the vesicles, he shows, is not sweat, but serum ; and the 
reaction of the fluid is alkaline or neutral in its early 
stages, never acid. It also contains a large amount of 
albumin and some fibrin. It comes from the papillary 
bloodvessels, and passing between the rete cells collects 
in different situations in the stratum mucosum. 



510 DISEASES OF THE SKIN. 

Diagnosis. Pompholyx must be differentiated from 
eczema, scabies, pemphigus, and erythema bullosum It 
differs from eczema in its vesicles not tending to break 
down of themselves ; in not presenting a moist surface 
after the vesicle tops fall ; and in running a more definite 
course. The sago-grain-like appearance of the vesicles is 
not peculiar to it, as it is frequently seen in eczema of the 
hands, and is due to the thickness of the epithelium pre- 
venting the ready escape of the fluid. Scabies may bear 
a close resemblance to pompholyx, but can be readily dif- 
ferentiated by finding the burrows, and noting the loca- 
tion of the eruption upon the anterior face of the wrists, 
the breasts in women, the genitals in males, and about the 
umbilicus in both sexes. Pemphigus of the hands and feet 
is exceedingly rare in adults, and pompholyx has never 
been reported in infants. Moreover, pemphigus lacks 
the vesicular lesions of the sides of the fingers. Erythe- 
ma bullosum is always on the back of the hands and 
wrists, and is not itchy, though it may burn. 

Treatment. A simple astringent ointment, as of 
oxide of zinc, or diachylon ; or one of the oleate of zinc 
or lead ; or an alkaline lotion, will allay the irritation 
and hasten the disappearance of the disease. Lassar's 
paste with 10 to 20 grains of salicylic acid to the ounce 
is a good application. It hastens the exfoliation of the 
old skin. When that has taken place it may be con- 
tinued, without the salicylic acid, to promote healing. 
General hygiene should be enforced ; and tonics of iron, 
arsenic, or whatever seems indicated by the condition of 
the patient, given. 

Porcellanfriessel. See Urticaria. 

Porcupine Disease. See Ichthyosis. 

Porrigo Contagiosa. See Impetigo contagiosa. 

Porrigo Decalvans. See Alopecia areata. 

Porrigo Favosa. See Favus. 

Porrigo Furfurans. See Trichophytosis capitis. 

Porrigo Granule. See Pediculosis. 



POROKERATOSIS. 511 

Porrigo Larvalis. See Impetigo. 
Porrigo Lupinosa. See Favus. 

Porokeratosis. Synonyms : Hyperkeratosis atrophica 
seii excentrica. 

Under this name Mibelli, 1 and later Respighi, 2 have 
described a disease of the skin that occurs in the form of 
raised or sunken yellowish-gray to brown patches of vari- 
ous sizes and irregular shape, with a continuous thin, 
horny, linearform tortuous ridge about them. The patch 
may begin as a very small, horny, dry, hard and acu- 
minate elevation which seems to well up from the orifice 
of a cutaneous gland. Around this the collarette forms. 
The skin inside of the border may be normal, rugous, 
smooth, scaly, or atrophic; while around the patches it 
may be normal, hypersemic, or pigmented. The amount 
of atrophy varies being most on the face and over bony 
prominences. The disease occurs on the dorsal and 
palmar surface of the hands and feet, the extensor surface 
of the forearm and leg, and exceptionally on their flexor 
surface. On the palms and soles and sides of fingers it 
takes the form of corns. It may also occur on the face, 
neck, and scalp, and the mucous membrane of the mouth. 
In the mouth the lesions vary in size from small pinhead 
to large lentil. They are sharply limited, with a linear, 
white, opaque border enclosing an opaline area that may 
be raised or flattened, convex or concave, or atrophic. 
There are no subjective symptoms. Some of the lesions 
may disappear spontaneously, and neighboring lesions 
may melt into each other. Generally the disease spreads 
slowly so as to occupy large areas. 

Respighi describes five distinct forms: 1. Miliary and 
submiliary papules ; 2. Hemp-seed- to lentil-sized pa- 
pules ; 3. Guttate to nummular papules ; 4. King and 
circinate disks, which is the most common form. Their 

1 Monatshefte f. prakt. Dermat., 1893, xvii., 417, also Annal. derm. 
et syph., 1905, vi., 503. 

2 Monatshefte, f. prakt. Dermat., 1894, xviii., 70. 



512 DISEASES OF THE SKIN. 

edges are raised, regular, toothed, or zig-zag, and may be 
composed of papules arranged in chains. The disks may 
be round, oval, or elliptic ; 5. Ball-shaped lesions three to 
four millimeters high. All forms begin as papules. The 
disease is bilateral and tends to symmetry. The nails 
may be affected, becoming cloudy, striped longitudinally, 

Fig. 69. 




Porokeratosis. (Respighi.) 

rough, thickened, raised from their bed, brittle, and they 
may be shed. 

The disease usually begins in early life, but may begin 
at any age. It is hereditary in some families. Most of 
the cases are in males. Many members of the same 
family may be affected. It is a very rare disease without 
known cause. It consists in a hyperkeratosis of the 



PRURIGO. 513 

sweat-gland orifices and destruction of the glands. The 
sebaceous glands and hair follicles may be involved in 
the process. It is thought by Mibelli to be a species of 
papilloma lineare. It is an eminently chronic affection. 
The treatment consists in destruction by electrolysis 
or in excision. 

Port-wine Mark. See ISaevus. 

Post-mortem Warts. See Tuberculosis verrucosa cutis. 

Prairie Itch. This disease has been found to be in 
most cases a combination of pruritus hiemalis and scabies. 
It is not a disease sui gene?*is. 

Prickly Heat. See Miliaria. 

Prurigo. Synonyms : Strophulus prurigineux ; Scrofu- 
lide boutonneuse benign e ; (Ger.) Juckblattern. 

A chronic disease of the skin characterized by begin- 
ning in infancy as an urticaria, and changing into a 
recurring eruption of pale, hard, exceedingly itchy, dis- 
crete papules, especially upon the extensor surfaces of the 
extremities. It increases in severity from above down- 
ward, aud is accompanied by enlargement of the inguinal 
glands. 

There are two types of this disease, namely, prurigo 
mitis and prurigo ferox. These blend into each other. 
While the malady is more commonly reported from 
Vienna than elsewhere, it occurs in many countries. It 
is rare in this country, and most of the cases met with 
are of the mild type. 

Symptoms. The disease begins in infancy, quite com- 
monly toward the end of the first year, as an outbreak of 
urticarial wheals of various sizes and shapes. It may be- 
gin in childhood. The urticarial eruption persists, but after 
a time a preponderance of small wheals will be remarked, 
and a preference for the trunk and the extensor surfaces of 
the limbs. During the second or third year the urticarial 
element is lost, and the characteristic papular eruption grad- 
ually preponderates, and at last takes its place. The pap- 



514 DISEASES OF THE SKIK 

ules are pinhead to hemp-seed in size, flat, firm, of the color 
of the skin, or of a bright-red, rosy, or yellowish-white 
color, and in many cases so little raised as to be felt rather 
than seen. When the skin is irritated the papules may 
assume the character of small wheals. The efflorescences 
are located principally upon the extensor surfaces of the 
limbs, and more sparsely on the trunk, while the scalp, 
the flexures of the large joints, the palms, soles, and geni- 
tals are free. The flexure surfaces of the extremities may 
be affected. The papules are not grouped. 

Pruritus is intense, so that excoriations and torn pap- 
ules are present over all the affected parts. The patients 
have a pale, weary expression of countenance, and evi- 
dently are in poor condition. The skin is often dry and 
it may be scaly. 

When the lesions are but few in number and scattered 
about upon the extremities we have prurigo mitis. When 
a great number of papules are present, and the disease is 
widespread, we have prurigo ferox. Now we have the 
typical form of the disease such as is shown in the Vienna 
skin clinics. We note that the skin feels rough ; that it 
is strewn over with a great number of small papules which 
are of the color of the skin or pale red ; defaced with 
scratch-marks ; eczematous in places ; darkly pigmented, 
it may be brown, from the constant irritation of scratch- 
ing, and that the color of the general integument is in 
strong contrast with the pale color of the face; that the 
skin is thickened in some places, while the flexures of the 
joints are free from change and as soft as normal ; that 
these changes in the skin are progressively worse from 
above downward, so that the legs from the knees down 
are most markedly involved ; and that the femoral glands 
are enlarged so as to form buboes. Ecthymatous lesions 
may arise. The intensity of the itching may be so great 
as to prevent sleep, and even in some cases to drive the 
patient insane. 

The duration of the disease is indefinite ; it may last a 
lifetime, but often tends to disappear with advancing 



PRURIGO. 515 

years. The type of the disease remains the same through- 
out — that is, prurigo mitis does not change to prurigo 
ferox. 

Etiology. Prurigo affects both sexes, though it is 
more prevalent in the male sex. It is far more common 
among the poor, especially Europeans, and those who are 
uncleanly. It is not very common in this country, spe- 
cially in the ferox type. It is not uncommon to find 
several members of the same family with the disease. A 
phthisical family history has been affirmed to be an etio- 
logical factor by some authorities. Some cases are better 
in winter and some in summer. It is a disease of infancy 
continuing through life. It seems to be related to urti- 
caria. A neurosis probably is the underlying cause of 
the disease. 

Pathology. The prurigo nodule is caused by an 
interstitial oedema of the rete, with the eventual formation 
of vesicles. The papillae are likewise oedematous, and 
show perivascular infiltration. The early lesions much 
resemble urticarial papules. 

Diagnosis. The diagnosis is made by the occurrence 
of pale papules upon the extensor aspects of the limbs ; 
by the increasing severity of the symptoms from above 
downward; by the enlargement of the inguinal glands, 
by the peculiar look and complexion of the patient, and 
by the continuance of the disease from early infancy. It 
is differentiated from eczema by the sparing of the flexures 
of the joints ; by the presence of the characteristic pap- 
ules, and by its greater obstinacy to treatment. From pap- 
ular urticaria it can be distinguished only by its general 
course In fact, a doubtful case must be carefully studied 
over a considerable length of time before a positive diag- 
nosis can be made. Scabies and pediculosis can be readily 
separated by the occurrence of the lesions on the palms, 
between the fingers, and on the genitals in the one ; and 
the parallel scratch-marks over the shoulders in the other. 
Ichthyosis spares the flexures as does prurigo, but it is 
marked by polygonal scales, not papules ; and is free from 



516 DISEASES OF THE SKIN. 

the great number of excoriations found in prurigo ; it is, 
moreover, a disease that affects the whole body-surface 
more generally. 

Teeatment. The disease is exceedingly obstinate to 
treatment. The patient must be put in as good a physical 
condition as possible by means of hygiene, cod-liver oil, 
iron, and a good diet. Tincture of cannabis indica is 
commended by Crocker for relief of the itching, in doses 
of 5 minims increased to 30 minims to a ten-year-old 
child, given three times a day directly after meals, 
and intermitted for two weeks after every six weeks. 
These seem to me to be large doses. Simon 1 and others 
recommend pilocarpin hypodermically, 15 minims of a 
2 per cent, solution once a day, for adults, or a corres- 
ponding quantity of jaborandi by the mouth. After the 
dose the patient is to be put in bed and covered with 
woollen blankets, where he is allowed to sweat for two 
or three hours. Carbolic acid, 5 to 10 grains a day in 
pill, and the bromide of potassium have their advocates. 
Antlpyrin and phenacetin exert a controlling influence 
over pruritus, and they are among the most valuable 
internal remedies in prurigo. The latter, though not so 
active as the former, should be tried first in full doses, 
as it is much safer. Thyroid extract has been recom- 
mended. 

External treatment is very important. Naphtol is most 
highly commended, a 2 to 5 per cent, solution, accord- 
ing to age, being rubbed in every night, and a bath of 
naphtol-sulphur soap being taken every second night. 
In older children and adults the soap treatment of Hebra, 
as described in the section on Eczema, is useful. Sulphur 
ointment used as in scabies after a daily bath ; tar used 
as in psoriasis ; a 5 or 10 per cent, lotion of carbolic or 
salicylic acid, or the same combined with vaseline ; a 5 
per cent, boric acid ointment, all have their advocates, and 
all may be tried in obstinate cases. Baths followed by 
inunctions of cod-liver oil, simple oil, tar oil, or lard, are 
1 Berlin, klin. Wochenschr., 1879 ? xvi., 721, 



PRURITUS CUTANEUS. 517 

often useful ; as well as baths of alum, soda, and corrosive 
sublimate. Jacquet and Tenneson report great ameliora- 
tion from wrapping the affected parts in some protective 
dressing, such as rubber sheeting or absorbent cotton. The 
spinal douche might do good in some cases. Treatment 
should be continued for weeks or months after apparent 
cure of the disease. 

The prognosis as to cure is bad, excepting in recent 
and not severe cases. These may be cured. As a rule, 
all we can do is to mitigate the patient's discomfort. Re- 
lapses are the rule. A few young patients become well 
as they reach full maturity. 

Pruritus Cutaneus. Symptoms. By pruritus cutaneus 
we mean a functional neurosis of the skin whose only 
essential symptom is itching. This induces scratching, 
and scratch-marks are always to be found as a secondary 
symptom. These usually are in the form of scratched 
papules. If the itching is great and continuous, we will 
have other secondary effects, such as thickening and 
pigmentation of the skin, and eczema of various degrees. 

The itching varies greatly in degree, from simply an 
occasional slight attack to such an intensity as to render 
the patient's life unendurable and tempt to suicide.. The 
pruritus is commonly paroxysmal, but in some cases the 
pauses between the paroxysms are so short that the itch- 
ing is practically continuous. It is almost always worse 
at night, and robs the sufferer of sleep. Changes of tem- 
perature aggravate the itching, as a rule. Very com- 
monly warmth makes matters worse, and the sufferer will 
begin to scratch and keep on scratching while in the 
neighborhood of a fire or in bed warmly covered. He 
cannot resist the impulse to scratch, and so in bad cases 
he shuns society and becomes morbid. 

Under the general title of pruritus are often placed 
various paresthesia?, such as formication, tingling, and 
burning. 

The pruritus may be general or local. Thus we have 



518 DISEASES OF THE SKIN. 

pruritus universalis, a term that is rarely to be applied 
with strict accuracy, as it is seldom universal, but only 
general. In these cases the itching is now in one place 
and now in another. Bulkley, 1 by a series of observa- 
tions on himself, strove to establish some law of reflex 
excitation, in which he was so far successful as to find 
that if he scratched one spot that itched, he relieved the 
sensation there, only to have it break out elsewhere. 
This general pruritus is most often encountered in pruri- 
tus senilis, or the itching of the skin of old people, and in 
pruritus hiemalis and pruritus aestivalis, which are induced 
respectively by the cold of winter or the heat of summer. 
These very often manifest themselves on the thighs and 
legs only. Bath pruritus is that form of itching which 
comes on after taking a bath, and lasts a variable time. 
Stelwagon has found that if the clothes are put on the 
itching lasts for a shorter time than when the patient 
goes to bed. 

Of local pruritus we have many instances. Thus we 
have pruritus ani, which afflicts both sexes, though more 
often men than women, and in which the itching extends 
to the mucous membrane of the anus. This same exten- 
sion is also seen in pruritus vulvae. This localized itch- 
ing, with the corresponding pruritus scroti in men, often 
occurs in connection with pruritus ani. In all these 
three the parts almost always becomes thickened and ec- 
zematous from the constant rubbing and scratching to 
which they are subjected, and nymphomania is some- 
times a consequence of the itching vulva. The scalp, 
face, especially about the nose and mouth ; the palms and 
soles, and between the fingers and toes, are frequent sites 
of itching. More rarely local areas anywhere will be 
affected with recurring attacks of itching. 

Etioloqy. That the pruritus is due to a functional 
disturbance of the sensory nerves there is no doubt. Ac- 
cording to Bronson 2 it is due to a disturbance of the sense 

1 Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 459. 

2 Med. News, April 18, 1903. 



PRURITUS CUTANEUS. 519 

of contact. Those with naturally dry skin are more apt 
to suffer than those whose skin is moist. For success 
in treatment and accuracy in prognosis it is necessary for 
us to endeavor to determine the cause of such disturb- 
ance. The contact of wool irritates some skins. Hepatic 
derangements cause a certain proportion of cases. The 
intense itching of the skin in jaundice is evidence of this. 
Digestive disorders and constipation ; excretory dis- 
orders, as of the kidneys and skin ; albuminuria ; lithae- 
mia ; and diabetes, all have influence in causing pruritus. 
Depressed mental states, and the disorders of the nervous 
system induced by the abuse of tobacco, tea, alcohol, 
opium, and the like, produce pruritus. Pruritus is not 
infrequently met with during the menopause. Reflex 
influences from the sexual sphere and the power of imag- 
ination are responsible for some cases. In illustration of 
the latter everyone knows how many people will begin 
to scratch when the subject of lice is mentioned ; and how 
that long after the acarus is killed in scabies the patient 
will continue to complain of itching, and will not be 
assured that he is cured of his disease. 

In pruritus senilis the skin will be found to be atro- 
phied and the fatty tissue underlying it absorbed, in not 
a few cases. Pruritus ani is often due to haemorrhoids 
or fissures of the mucous membrane ; or to ascarides ; or 
to the excessive use of tobacco, as well as to the causes 
enumerated above. Stricture of the urethra has been 
found to be the cause of both it and pruritus scroti. 
Pruritus vulvae is very often due to leucorrhoea, preg- 
nancy or tumors of the uterus or ovaries, or occurs 
during the menopause. In this form diabetes is quite 
commonly the cause. Pruritus hiemalis begins at any 
time from October to January, and continues until the 
spring is well advanced. The effect of cold upon the 
skin seems to check the secretory functions. 

Bulkley has found pruritus to be more common in men 
than in women, fifty of his eighty cases being men. In 
some families an itching skin seems to be hereditary. 



520 DISEASES OF THE SKIN. 

Diagnosis. If we bear in mind that pruritus has no 
lesion of its own ; and if, whenever a patient complains 
of itching of the skin, we institute a search for the pedic- 
ulus, or the itch-mite, or their lesions ; or the wheal, or 
at least a history of it ; and find none, then we have by 
elimination gone far toward establishing a diagnosis of 
pruritus. Sometimes it is difficult to determine whether 
an eczema is secondary to the scratching for the relief of 
itching, or the itching is a part of the eczema. Only an 
attempt at curing the eczema and long observation of the 
case will enable us to make a true diagnosis. Many errors 
of diagnosis will be changed by close study, as true pruri- 
tus is not so common as other itching diseases. Bulkley 
found but 80 cases in 5000 private cases. 

Treatment. To find and remove the cause is the first 
essential in treating a case. How difficult this task may 
be will be seen by a study of its etiology. Nevertheless, 
the patient must be considered, and every organ interro- 
gated, and every deranged function regulated as far as 
possible. Tea, coffee, alcohol and tobacco should be 
interdicted ; a dietary carefully laid down ; and the rules 
of hygiene, such as those relating to exercise, bathing, 
and clothing, enforced. To relieve the itching as such, 
we may give the tincture of cannabis indica, 10 minims 
three times a day, in water after meals, and gradually 
increase the dose up to 20 or 30 minims ; or the tincture 
of gelsemium in 10-minum doses every half-hour till 1 
drachm is taken or toxic effects produced ; hypodermic 
injections of pilocarpin ^ to J of a grain ; quinin, 10 to 
15 grains at bedtime ; carbolic acid, 1 to 2 minims three 
times a day and increased ; wine of antimony, 5 to 7 
drops after meals ; salicylate of soda, 1 5 grains, or anti- 
pyrin or phenacetin in full doses. Besnier recommends 
valerian, or valerianate of ammonium. But the relief 
so obtained is transitory, and we should not rest content 
uutil we have found out, and where possible removed, 
the internal underlying cause. Opium should never be 
given, as it causes pruritus. 



PRURITUS CUTANEU& 521 

The external treatment is of great service in alleviating 
the itching, even if it does not cure the disease. For this 
purpose general baths with soda (gviij-x to 30 gallons), 
or nitric or hydrochloric acid (§j to 30 gallons), may be 
used. After the bath the body is to be dried by wrapping 
in a warmed sheet and patting the skin dry ; then the 
skin should be smeared with vaseline and powdered with 
cornstarch from a flour-dredger. For local pruritus we 
may use lotions, of which one of the most efficient is : 



R Acid, carbol., gi-ij 12-25 

Liq. potasse, 3j ; 12 

01. lini., ad |j ; 100 

Sig. Shake before using (Bronson). 



M. 



The patient should be cautioned to tap the itching point 
gently with this, and not rub it in. So used, it will 
cause no damage and may stop the itching for hours. Car- 
bolic acid may be used as a spray in the strength of J an 
ounce to the pint of water with 1 ounce of glycerin. To 
this 5 to 20 minims of oil of peppermint may be added 
(Hardaway). Alkaline lotions, as bicarbonate of soda, 
5j to the cupful of water ; or acid lotions, such as viu- 
egar dabbed on the itching spot, will often relieve. Liquor 
carbonis detergens 5j to §iv ; or thymol, 5ij ; liquor potas- 
so3, 5j ; glycerin, oiij ; aquse, gviij (Crocker). Liquor 
picis alkalinus, 5j to 5iv; or per chloride of mercury, gr. 
j— 3 to oj of water. All these are well attested as useful. 
Peroxide of hydrogen is highly commended by Bronson. 
It may be used as a toilet wash two or three times a day. 
For pruritus ani, scroti, et vulvm sitting over a basin 
or pail of very hot water and sopping it up on the parts, 
followed by patting the skin dry and using a starch 
powder, will often give the patient a quiet night. If an 
eczema is present, that must first be cured. Cocaine 
lotions, as one of 20 per cent, of cocaine and 5 per cent, 
of glycerin ; or menthol 3 to 10 per cent, in oil of sweet 
almonds, or of glycerin and water; and carbolic acid lotions 
are also useful, as well as the ointment of the ammoniate or 



522 DISEASES OF THE SKIN. 

nitrate of mercury. Schafer 1 says that bromotan, 10 per 
cent, in equal parts of lanolin and vaselin applied on a band- 
age two or three times a day cures quickly. Cocaine had 
best be left alone, as there is always danger of forming the 
cocaine-habit from the use of this seductive drug. Bulk- 
ley's antipruritic powder, of 1 drachm each of camphor 
and chloral, rubbed together till liquefied, and added to 
1 ounce of starch powder, will sometimes prove very 
effective. Painting the parts with nitrate of silver, gr. 
xvj in spts. setheris nitrosi §j, is another good proceeding. 
A saturated solution of boric acid is also good. When 
the parts are excoriated neither menthol, peppermint, nor 
the chloral-camphor powder can be used. Guaiacol 5 or 
10 per cent, with starch powder, is one of the newer 
remedies. Suppositories containing belladonna, cocaine, 
or creosote may give relief in these cases. Of course, 
haemorrhoids, fissures, or other rectal diseases must be 
cured if found. The high frequency current or the 
Rontgen rays may be used with great benefit. W. M. 
Banks 2 recommends in pruritus ani the use of the large 
bulbous-headed point of the Paquelin cautery, so as to 
frizzle the skin for an inch and a half about the anal 
orifice. If there are rugous folds a smaller cautery should 
be used. 

In pruritus hiemalis it is sometimes necessary for the 
patient to wear linen underclothing next the skin ; and 
over it the woollens usually worn. Other patients find 
more relief from wearing silk underclothing. The treat- 
ment indicated above for pruritus is applicable here also. 
In some cases the only relief is found in removal to a 
warmer climate. 

In some obstinate cases of general pruritus great ame- 
lioration may be obtained by the actual or Paquelin cau- 
tery applied lightly along the spine. The same means 
has sometimes been successful in localized pruritus, as of 
the vulva or scrotum, but now the parts themselves are 

1 Frauenarzt, 1906, xxi. , 2. 

2 Brit. Med. Journ., 1900, i., 561. 



PSORIASIS. 523 

touched with the cautery. Spinal douches are highly 
thought of by some French authorities. Iu these chronic 
cases it must be remembered that a cure can be effected 
with difficulty as long as the patient is exposed to the wear 
and tear of his life. Many nervous patients are well when 
travelling or living out-doors. 

Prognosis. The prognosis is doubtful. Some cases 
are very obstinate, and some are incurable. Happily, 
thorough study of the case will be rewarded in most 
cases by a cure. 

Pruritus Hiemalis. See Pruritus cutaneus. 

Pseudo-exantheme Erythemato-desciuamatif. See Pity- 
riasis rosea. 

Pseudo-erysipelas. By this term is meant cellulitis or 
diffused phlegmon. 

Pseudo-leucasmia Cutis is a very rare disease. It is a 
form of Hodgkin's disease. A case is reported by 
Joseph 1 as occurring in a man in previous good health. 
It commenced as a number of small glandular swellings 
in the neck. Shortly after their appearance severe gen- 
eral pruritus began to affect the patient. Then the 
inguinal and axillary glands became greatly enlarged, 
and a general eruption of hemp-seed-sized papules occur- 
red. These were more easily felt than seen, and were 
of a pale-red color. The epidermis over them was un- 
changed. Wheals also appeared that changed into pap- 
ules. The skin between the papules was dark-colored, 
thickened, and dry. The case ran a chronic course, 
marked by relapses. 

Pseudo-lupus. See Dermatitis blastomycotica. 
Psora. See Psoriasis. 

Psoriasis. Synonyms : Lepra Grecorum ; Lepra al- 
phos ; Alphos ; Psora; (Ger.) Schuppenflechte. 

A disease of the skin characterized by an eruption of 
round or oval, bright-red patches covered with more or 

1 Deutsche med. Wochenschr. , 1889, p. 946. 



524 



DISEASES OF THE SKltf. 



less thick, silvery-white, adherent scales ; by occurring 
especially upon the extensor surfaces of the elbows, knees, 
and extremities, and upon the scalp ; by running a chronic 
course marked by remissions and relapses ; and by being 
more or less pruritic. 

This is one of the more common skin diseases, forming 
in this country about three per cent, of all cases." 

Fig. 70. 




Psoriasis. (From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 

Symptoms. Its features of variously sized, sharply 
defined red papules or patches covered with more or less 
abundant silvery-white scales that occur especially upon 
the extensor surfaces of the elbows and knees, are so pro- 



PSORIASIS. 



525 



Dounced that the disease once seen is readily recognized 
even by the tyro. 

The primary lesion of psoriasis is always a pinkish or 
bright-red, pinhead-sized papule covered with a dry sil- 
very-white or grayish scale. It is rare to meet with a 



'ig. 71. 




Psoriasis. (From Prof. G. H. Pox's service in the Vanderbilt Clinic.) 



case in which these small lesions are seen alone, and when 
it is, it is called psoriasis punctata. Careful search of any 
but an inveterate case will be rewarded by finding these 
lesions somewhere on the body. They soon begin to en- 
large by peripheral extension into larger patches, which 
have received various names, although preserving the 



526 DISEASES OF THE SKIN. 

same essential characteristics. When they attain the dia- 
meter of about one-quarter of an inch, and bear a rather 
thick scale, they look like drops of mortar, and the case 
is then spoken of as psoriasis guttata. When the lesions 
form coin-sized patches we speak of psoriasis nummularis. 
A single patch may grow to be two inches in diameter, 
or even larger, and preserve its circular shape. But the 
large patches are usually formed by the coalescence of 
several smaller patches, and may attain to a size sufficient 
to cover the greater part of a limb or even the trunk. 
Its circular outline is now lost, and the patch has a more 
or less scalloped, indented border bearing so strong a re- 
semblance to the maps drawn by children that Piffard 
suggested the term psoriasis geographica for it ; but the 
more usual name is psoriasis diffusa. After a patch has 
reached a certain size it may clear up in the centre and 
form a ring, and in this way we have psoriasis ciscinata. 
Several of these rings may meet at their circumference, 
when the points of contact will disappear and gyrate fig- 
ures will be formed. When the eruption is so general 
as to involve the whole or greater part of the body, we 
speak of it as psoriasis universalis. Not infrequently 
these cases bear a striking resemblance to dermatitis ex- 
foliativa. 

Every case of psoriasis does not exhibit all these varie- 
ties, because the disease may stop at any period of its evo- 
lution. But in any case there is apt to be a number of 
variously sized lesions. Whatever the size of the patch 
may be, it will always be observed that the redness ex- 
tends but little beyond the scales. The amount of the scal- 
ing will vary. Sometimes the scaling will be but slight ; 
sometimes it will be so abundant that it will heap up into 
such crust-like masses as to suggest the adjective rupioide. 
The scales are constantly being shed, and as constantly 
renewed. They may be readily scraped off with the nail ; 
and if this is carefully done, a delicate glistening mem- 
brane will be exposed, under which will appear dot-like 
red points. That is ; we have removed the epidermis and 



PSORIASIS. 527 

exposed the mucous layer of the skin, the red points be- 
ing the tops of the slings of bloodvessels of the papillae. 
This is thought by some to be characteristic of psoriasis, 
but with care it may be produced in other diseases. 

The color of the scales is silvery white or grayish. 
Darker scales are due either to the deposition of dust or 
the admixture of blood. The color of the patch will vary 
from a pinkish red to a dark red, the darker color being 
seen upon the legs, where the color of all lesions is darker 
on account of the partial stasis in the return flow of blood. 
The disease is always a dry one, there being absolutely 
no discharge feature in its course. The patches are 
sharply defined, but so little raised that they can be nearly 
all scratched away. j 

While psoriasis may occur anywhere on the body, and, 
as we have seen, may become universal, its most frequent 
locations are the extensor surfaces of the limbs, elbows, and 
knees, or rather the face of the tibia just below the knee, 
and the scalp. It may occur upon the first two locations 
alone. When it occurs upon the scalp careful examination 
will generally show some lesion elsewhere on the body, and 
we will usually find a little patch in front of the ears, and 
very often there will be a red scaly line on the forehead 
just in front of the hair-line, a feature that is as striking 
and as characteristic of psoriasis as the corona veneris is 
of syphilis. The hair does not fall, as a rule. In some 
cases, however, we may have transient or permanent 
alopecia. The whole scalp may be covered with a con- 
tinuous patch, or distinct scaly patches may form as on the 
body. In any event the border of the patch will be 
sharply defined. It is very rare to find psoriasis on the 
mucous membrane of the mouth. M. Oppenheim x has 
seen one case developing there in connection with marked 
psoriasis of the rest of the body. It appeared in the form 
of bluish- white, sharply defined, oval, raised patches of 
various sizes. 

The palms and soles are very rarely the seat of the dis- 
1 Monatshefte f. prakt. Dermat., 1903, xxxvii., 489. 



528 



DISEASES OF THE SKIK 



ease, and then only as part of general psoriasis. It is 
true that a few cases have been reported in which it has 
been said even to be located upon one hand alone, and this 



Fig. 72. 




Fig. 73. 




Psoriasis of the palms. (By the courtesy of Dr. S. I. Rainforth. 



by competent observers ; but all the probabilities are in 
favor of such cases having been either syphilis, which 
is most likely, or squamous eczema. The disease is 



PSORIASIS. 



529 



bilateral, and sometimes may show a decided tendency to 
symmetry. 

In old, inveterate cases there may be considerable thick- 
ening of the skin, a feature that is usually wanting, and 
fissures may form about the joints that maybe painful and 
bleed. This may also occur on the scrotum, or on the 
trunk where the skin is in folds. 

The nails are affected in some cases, becoming opaque, 

Fig. 74. 



Psoriasis of the sole. (By the courtesy of Dr. S. Dana HdbbAed.) 

lusterless, furrowed transversely, discolored, and some- 
times cracked ; while they are raised from their beds by 
the accumulation of scales underneath them. All the nails 
are rarely diseased at the same time ; usually it is but one 
or two nails on each hand or foot. Sometimes the disease 
is limited to a strip along the side of one nail. 

There is no constitutional disturbance in this disease, 
the patients usually being in as good health as the majority 
of mankind. Sometimes they have pains in the joints 
that are regarded as rheumatic by some, and as neurotic 
by others. Itching is very often an annoying symptom. 
Sometimes it is entirely wanting. 
34 



530 DISEASES OF THE SKIN. 

The course of the disease is variable. Although it is 
always chronic, it presents at times acute symptoms. 
Relapses are the rule, to which there are few exceptions. 
In some cases the skin will be entirely free from all trace 
of the disease for months or years. In most cases this 
freedom is only partial ; even though the patient thinks he 
is clean, some little spot will be discoverable. The dura- 
tion of each patch is also variable. It may disappear in a 
few weeks or remain for months. Most cases are better 
in summer, to become worse in winter. When the patches 
disappear, they do so completely, though a slight amount of 
scaling may be present for a short time. Lederman * has 
seen leucoderma follow the disappearance of the lesions. 
In a few very rare cases a chronic psoriatic patch has 
become papillomatous and then epitheliomatous. 

Etiology. Various theories have been advanced in 
the etiology of psoriasis, and some facts have been estab- 
lished by our study. We know that the disease is hered- 
itary in a number of cases. Greenough 2 found the pro- 
portion as high as one-third. It may occur at any age. 
Kaposi has reported a case at eight months of age, and 
Riehl 3 one at thirty-eight days. Whitfield has had one 
case three weeks old. It usually is a disease of early 
adult life, making its first appearance before the thirtieth 
year. A primary attack is rare after the fiftieth year. 
It affects both sexes and all conditions of life. These 
things we know. 

While the majority of patients seem to be in the best 
of health, some are rheumatic or gouty. In some cases 
there will be an unusual amount of indican in the urine. 
A lowered condition of the general health seems, in some 
cases, to favor an outbreak either of a primary attack or of 
a relapse. Thus it is no uncommon thing to see the disease 
in women grow worse during pregnancy or lactation. 
Malassimilation or digestive disorders also seem to aggra- 

1 Archiv. f. Dermat. u. syph., 1907, lxxxiv., 359. 

2 Boston Med. and Surg. Journ., 1885, cxiii., 163. 
3 Monatshefte f. prakt. Dermat., 1895, xxi, 283. 



PSORIASIS. 531 

vate or provoke the disease, Hardaway even affirming that 
he has known the inordinate eating of oatmeal to cause 
the disease, while Gowers 1 reports cases produced by the 
ingestion of borax as a medicine. Hyde is inclined to 
believe that as the disease occurs most upon covered parts, 
deprivation of the skin from contact with the sun's rays, 
may be one cause of it. Polotebnoif 2 has written an 
elaborate thesis to show that the disease is a vasomotor 
neurosis, affirming that in a majority of cases there will 
be found evidences of either trophic or vasomotor disturb- 
ances, or a history of more or less profound nervous 
troubles either in the patient or his family. A number 
of cases following fright or nerve-shock have been re- 
ported. In the Vierteljahr. f. Derm, u, Syph. for 1878, 
Lang brought out his parasitic theory, and in No. 208 of 
Volkmann's Sammlung klin. Vortrdge the thesis is further 
elaborated, the fungus being represented by illustrations. 
He has found some support from other observers, but the 
parasite he described has not been accepted as the cause of 
the disease. Destot produced the disease in a man by 
inserting a piece of psoriatic skin into a freshly scarified 
place. This was followed by an eruption of psoriasis 
which ran the usual course with four relapses in two years. 3 
Crocker accepts the parasitic theory, and accounts for the 
wide distribution of the disease by assuming that the 
parasite gains entrance into the blood from the point of 
inoculation, and through the circulation affects the general 
skin. 

It is a well-known fact that an injury to the skin of a 
psoriatic, such as a pin-scratch, will determine the loca- 
tion of a patch of psoriasis. 

Pathology. Pathologists by no means agree in their 
teachings as to the histology of psoriasis. By some it is 
regarded as inflammatory, while others believe it to be a 
keratolysis, or an anomaly of cornificatiou in which an 

1 Lancet, October 24, 1884. 

* Monatshefte f. prakt. Dermat., 1891, Erganzungsheft, No. 1. 

3 Hallopeau, Ann. de derm, et syph., 1901, ii., 337. 



532 DISEASES OF THE SKIM 

imperfect corneous layer is formed. Some teach that the 
process begins in the rete, and the changes in the corium 
are secondary ; while others hold the reverse view. Lang 
names his parasite epidermidophyton, and describes it as 
composed of ruycelia and spores, either disseminated or in 
groups, which are so delicate as to be seen only with very 
high powers. 

Histologically there appears to be a hyperplasia of the 
rete, except directly over the papillae, which latter are 
enlarged and more vascular than normal. The epi- 
dermis seems composed of only two layers, the thickened 
rete, and the parakeratotic corneous layer, the lamellated 
loosely coherent strata of which still retain their nuclei. 
There are serous cellular infiltrations in the upper corium, 
especially about the hair follicles, sebaceous glands and 
enlarged bloodvessels. 

Diagnosis. A typical case of psoriasis presenting 
round or oval, variously sized, pinkish-red, dry patches 
covered with thick silvery- white scales, scattered more or 
less generally over the body, but showing a marked 
preference for the extensor surfaces of the extremi- 
ties, and especially of the elbows and knees, is read- 
ily recognized. In some less typical cases it needs to 
be differentiated from syphilis, eczema, dermatitis ex- 
foliativa, lichen ruber, and lichen planus, seborrhoeal 
dermatitis, and possibly from lupus erythematosus. From 
the papulosquamous syphilide of the secondary stage of 
the disease it differs by showing preference for the ex- 
tensor surfaces of the limbs and the posterior surface of 
the trunk, though there are many exceptions to this rule. 
The syphilide is not so scaly ; its red is darker, more 
•raw-ham-colored ; the lesions are more infiltrated, giving 
a more shotty feeling to the finger ; they do not itch ; 
they run a more acute course, and are of more uniform 
size, never exhibiting the patchy character of psoriasis. 
It is usually easy to establish the presence of other mani- 
festations of syphilis, such as sore throat, pains in the 
bones, fall of the hair, and perhaps the remains of the 



PSORIASIS. 533 

initial lesion. The late scaly syphilide is never general ; 
is unsymrnetrical, usually consisting of one or two groups 
of lesions that show no tendency to affect the elbows and 
knees. The lesions are more raised and prone to leave 
scars. There will also be the history of past syphilides 
to guide us, and an absence of those relapses so common 
and characteristic of psoriasis. 

Eczema squamosum is far more pruritic than psoriasis 
usually is ; the patch is more infiltrated ; the scaling is 
less, the scales being thinner ; exudation can be readily 
induced ; and a history of moisture at some time will be 
found. The patch of eczema is generally less sharply 
denned, and is more apt to shade off into the surrounding 
skin. If the scales of a psoriatic patch are removed, a 
delicate membrane is left showing red dots — the tops of 
the bloodvessel slings in the papillae ; if the same thing 
is done in eczema, a discharging surface will be left. 

It is quite impossible to differentiate a true case of der- 
matitis exfoliativa at first sight from one of general pso- 
riasis. If it does arise from psoriasis, there will be a 
history of its gradual spread from topical lesions, quite 
different from what obtains in true dermatitis exfoliativa, 
which is more rapid in its evolution. Psoriasis is rarely 
so absolutely universal as is dermatitis exfoliativa. Watch- 
ing the case for a time will establish the diagnosis. If 
psoriasis is the malady, it will declare itself after a time 
by the diffused redness clearing up and typical psoriatic 
patches showing themselves. 

Lichen ruber presents small, pointed papules upon the 
trunk at first, and not the large scaling papules upon the 
extensor surfaces of the limbs of psoriasis. When the 
disease becomes general we will have the history of these 
lesions, and the skin will be more thickened and rugose. 

Lichen planus occurs by preference on the flexor rather 
than the extensor aspects of the limbs, and in the form of 
flat, shining, angular, smooth papules, rather than of 
round, freely scaly ones. The color of its patches is vio- 
laceous and not bright red. If it becomes universal, it 



534 DISEASES OF THE SKIN. 

does so evidently by the springing up of new small lesions 
between the old ones, and not by the peripheral growth 
and coalescence of those already existing. The thicken- 
ing of the skin is also much greater than in psoriasis. 

In the diagnosis from seborrheal dermatitis Unna lays 
great stress upon four points : 1. Seborrheal dermatitis 
spreads from above downward, mostly in the middle line 
of the body, and its lesions are quite stationary in char- 
acter ; while psoriasis begins on the elbows and knees, 
and more speedily affects the whole body. 2. There is 
always a history of a seborrheal affection of the scalp 
in seborrheal dermatitis. 3. The scales of seborrheal 
dermatitis are fatty and crumbling, and the patches are 
yellowish ; in psoriasis the scales are white and friable, 
not greasy, and the patches are bright red. 4. The 
proneness of the patches of seborrheal dermatitis to form 
bow-shaped figures, or rings more or less broken. Psori- 
asis may be circinate, but the margins of the figures 
are not so narrow and not follicular as they may be 
in seborrheal dermatitis 

Treatment. Though external treatment alone will 
often remove the evidences of psoriasis upon the skin, 
producing a cure of the disease — if that may be said of 
a disease that is almost sure to relapse — we generally can 
procure more prompt results by a combination of internal 
and external remedies. The first inquiry in all cases 
should be made as to the general condition of the patient, 
and we should endeavor to establish in him as perfect a 
state of health as is possible. A restricted diet certainly 
does have a good deal of influence in causing an amelio- 
ration of the disease, and most authorities forbid the use 
of red meats. No hard-and-fast lines can be set in this 
respect. In the service of Prof. George Henry Fox, who 
is a strong advocate of dieting in skin diseases, I have 
seen some patients improve under a strictly vegetable diet, 
and others do equally well on a dietary composed largely 
of milk and animal food. A stout, evidently overfed, 
plethoric patient will be benefied by cutting off all, or 



PSOBIASIS. 535 

nearly all, meat. In this class of patients it is a good 
plan to insist upon a milk diet for a few days. An an- 
aemic, underfed patient will, on the other hand, improve 
under a more liberal dietary. Alcoholics, and especially 
malt liquors, should be interdicted in all cases, as well as 
rich gravies and highly spiced foods. 

Besides these general measures we have a number of 
drugs that have gained a more or less well-earned reputa- 
tion as remedies for psoriasis, though it must be confessed 
that they are more or less empirical remedies. 

Arsenic would be named, without doubt, by most gen- 
eral practitioners as the remedy for psoriasis. It does do 
good in this disease, but at the same time it is not to be 
considered as a true specific. In acute cases it aggravates 
the disease and should never be given. In chronic cases 
that have proved very stubborn it may be tried, and some- 
times it will produce a speedy cure. When the disease 
begins to disappear, it will hasten its disappearance. The 
vast majority of cases will do quite as well without it. It 
may be given in the form of Fowler's solution with or 
without the wine of iron, and administered in water three 
times a day after meals. The initial dose for an adult 
should be about 3 drops, and the amount should be grad- 
ually increased until the limit of toleration is reached. 
Crocker thinks that the efficiency of this form of arsenic 
is enhanced by the addition of J a drachm of the tincture 
of lupulus to each dose. The Asiatic pill is the favorite 
mode of using arsenic in Vienna. It is composed, accord- 
ing to Kaposi, of — 



R 



Pulv. ac. arseniosi, 


gr. xj ; 




Pulv. piperis nigrae, 


3iss; 


6 


Gummi acaciae, 


gr. xxij ; 


1 


Pulv. althae. rad., 


gr. xxx ; 


2 


Aquas, 


q.s.; 


q. s. 


Div. in pil. No. c. 







M. 



One pill is given after meals, and the dose is increased 
gradually every four or five days until 10 or 12 are taken 
a day, unless some constitutional disturbance is caused 



536 DISEASES OF THE SKIN. 

before then. The method of increase is by first giving 
1 pill after each meal ; then 2' pills after breakfast, and 

1 after the other two meals ; and then 2 after breakfast, 

2 after the midday meal, and 1 in the evening, and so on, 
Or we may make use of the tablet triturates of arsenious 
acid with piperina, giving those containing -gL of a grain of 
the arsenic in the same manner as the Asiatic pills. Any 
other preparation of arsenic may be used. Hypodermic 
injections of arsenic or the cacodylate of sodium have 
been employed with success, but it would be hard to 
induce an American patient to endure this method. Stel- 
wagon reports occasional success from using in this way 
sterilized Fowler's solution with J- grain of carbolic acid . 
to 5 minims of Fowler's solution. He begins with 3 
minims of the mixture diluted with 4 or 5 parts of water, 
once a day. The administration of the drug must be 
persisted in for a long time, and it may prove curative 
by itself. It is best not to continue its use for more than 
three or four months, as it is apt to produce permanent 
and general pigmentation of the skin and keratosis. 

Alkalies that act as diuretics are often very helpful, 
quite apart from any indication for their use on account 
of gout or rheumatism. A beginning psoriasis, or even a 
case of some duration, will be favorably influenced by the 
administration of the acetate or citrate of potassium in 
15 -grain doses before meals, well diluted, and followed by 
drinking J a glass of water. The undoubted efficacy of 
large doses of the iodide of potassium, as recommended 
by Haslund, 1 may depend, in part at least, upon its diu- 
retic action. He gives the salt in increasing doses, so that 
as much as 600 grains have been administered to one 
patient during the day. When assistant physician to the 
New York Skin and Cancer Hospital, in Dr. G. H. Fox's 
division, I tried Haslund's plan in several cases. They 
certainly were greatly benefited. The objections to this 
method are the expense of the drug and the danger of the 
sudden production of poisoning, shown by palpitation of 
i Vierteljahr. f. Derm.u. Syph., 1887, xiv., 677. 



PSORIASIS. 537 

the heart, severe headache, and faintness, necessitating 
either the keeping of the patient in a hospital or under 
the constant attendance of a physician. 

Turpentine oil is highly commended by Crocker as fol- 
lows : It may be given in capsule, or, preferably, as an 
emulsion rubbed up with mucilage of acacia. The initial 
dose is 10 minims three times a day after meals. It may 
be increased by 5 or 10 minims at a dose until the patient, 
if tolerant of it, is taking 30 minims three times a day. 
Barley-water must be freely drunk during the day to 
prevent any bad effect on the kidneys, and the last dose 
of the turpentine should be taken not later than six or 
seven o'clock in the evening. Dyspepsia and irritability 
of the urinary organs contraindicate its use. The same 
authority advocates the use of salicylate of soda in 15- 
grain doses three times a day after meals, or saliein in 
dosage of 15 grains three times a day, increased to 20 
grains. 

The wine of antimony in 5- to 10-minim doses is re- 
commended by Sir Malcolm Morris as efficacious in acute 
cases. Hyde speaks well of the protiodide of mercury 
\ grain three times a day. 

Chrysarobin by the mouth, i of a grain in sugar of 
milk three times a day, and increased to 1 or 2 grains at 
a dose, acts well in some cases, but is very apt to cause so 
much nausea and vomiting as to compel its discontinuance. 
Carbolic acid in drop doses t. i. d. after meals, gradually 
increased, certainly is helpful in some cases. It may be 
exhibited in glycerin and peppermint water and is well 
borne. It may be given up to 20 grains a day. It can 
not be given to those who have any renal disease. 

Polotebnoff, believing the disease to be a neurosis, ad- 
vocates the use of bromide of potassium and of ergot. 

As most patients are worse in winter than they are in 
summer, when the skin is more moist from active perspi- 
ration, a residence in a mild climate might well be com- 
mended to a chronic psoriatic. 

External treatment. Before making any application to 



538 DISEASES OF THE SKIN. 

the psoriatic skin the scales must be removed by bathing 
with soap and water, or by warm alkaline baths. Some- 
times bathing followed by inunctions of the skin with 
simple oil, or vaseline, combined with attention to diet, 
will produce a cure. These measures should be tried first 
in all beginning cases. In some cases there will be 
well-marked eczematous conditions. Then we must use 
remedies applicable to that disease. Generally we must 
resort to more stimulating remedies. The most useful 
and most promptly curative external remedy is chrysarobin 
(chrysophanic acid). The objections to it are its tendency 
to produce an acute dermatitis and its permanent staining 
of everything with which it comes in contact. These 
unpleasant effects may be in part overcome by combining 
the drug with flexible collodion or traumaticin, but only 
in part. The dermatitis is always most marked upon 
those parts in which there is laxity of the skin, and if it 
is used on the face it is prone to produce great swelling 
about the eyes. Care must be taken not to get it in the 
eyes, as it causes violent conjunctivitis. These effects 
should make us very cautious about using it on the scalp, 
and prevent its use on the face. 

The most active form in which to use the drug is in an 
ointment, as of lard, lanolin, or vaseline. Gelanthum, 
and plasment are excipients that have the merit of not 
being greasy, and of being readily and entirely removed 
by means of water. Flexible collodion and traumaticin 
(liquid gutta-percha) are good excipients. The drug may 
be rubbed up with water into a paste and applied to the 
spots and then covered with a piece of oxide of zinc 
plaster. This is a neat way of using it where there 
are but few patches. 

The strength of chrysarobin should not exceed 1 drachm 
to the ounce, as a rule ; though in exceptional cases it 
may be used in greater strength. Its activity is increased 
by the addition of salicylic acid (3 per cent.), and then it 
is best to use it in a lower percentage, even 5 per cent, 
being active enough. An alkaline bath before using 



PSORIASIS. 539 

the chrysarobin increases its potency. If we use an 
ointment, it should be thoroughly rubbed in once a day 
after the scales are removed. If the vehicle is gelanthum, 
plasment, collodion, or gutta-percha solution, the spots 
should be painted over as often as the film left by the 
application falls. The patient should always be warned 
against getting the drug in his eyes. A favorite formula 
of Dr. George H. Fox is the following : 

R Chrysarobin., ) 

Ol.cadini, '} ™ 2 P arts ' 

Ac. carbolici, 1 part. 

Ac. oleic. 50 parts. — M. 

If the chrysarobin produces too great a reaction, it 
must be stopped, and the skin treated with vaseline and 
starch powder, or an alkaline wash ; or a smaller dosage 
may be tried, even as small as two or three grains to the 
ounce. The action of the drug upon the skin is peculiar. 
It stains the skin about the patches a mahogany red, 
while the patches become smooth and white. It discol- 
ors the nails and the hair, but after a time the staining 
disappears. Not so the staining of the clothing, which 
is permanent. It is said that it can be somewhat les- 
sened by soaking the clothes in plain water before using 
soap in washing. 

Before chrysarobin was discovered much reliance was 
placed on the ointment of the ammoniate of mercury. It 
is still a reliable remedy, but it cannot be used over 
the whole body in a general psoriasis on account of the 
danger of absorption of the mercury. It is the pleasant- 
est and promptest application to the scalp and face, and 
can be used there while chrysarobin is used on the rest 
of the body. An ointment of 

R Hydrarg. ammon., gr. xx; 125 

Hydrarg. chlor. mitis, gr. xl ; 2 50 

Petrolati ad ^j ; ad 32 M. 

is sometimes better than that of the ammoniate by itself. 
Other mercurial ointments, such as that of the yellow 
oxide, and a dilute ointment of the nitrate, may be used. 



540 DISEASES OF THE SKIN. 

Lang has found the bichloride of mercury in collodion in 
J to J per cent, strength a good application. It would 
probably be an unsafe one in a case of any extent. 

Tar is another old and reliable remedy, still much used 
in France. It may be employed in an ointment, or oil, 
or dissolved in alcohol. The oil of cade, oil of birch, or 
pure tar may be used in the strength of J- drachm to 4 
drachms to the ounce. In Paris the following is some- 
times used : 

R Glycerol, amyli, ) 

01 oadini, } aa «»P«ta- 

Sapo. viridis 5 " M. 

This is to be rubbed in at night ; the patient is to sleep 
in a flannel gown, and wash the ointment off in the morn- 



Kaposi recommends the following 


: 




R 01. rusci, 

^theris sulphuris, ) 
Alcoholis, J 


aa 


50 parts. 
75 " 


Filtra et adde 






Ol. lavandulae, 




2 " 



M. 

Tar in any form is a dirty application, and is prone to 
produce inflammation of the skin, as well as toxic symp- 
toms. Anthrasol, which is a colorless tar, should be used 
on exposed parts. 

Pyrogallol (pyrogallic acid) is efficacious, but can be 
used only in cases in which the eruption is not extensive, 
on account of its poisonous action when absorbed. It 
may be used in the strength of about 10 per cent, in 
ointment. It stains the skin, but causes less inflamma- 
tory reaction than chrysarobin does. 

Thymol was introduced by Crocker. It may be used 
as an ointment or lotion in the strength of 15 grains to 
3 drachms to the ounce. As it is colorless and of pleas- 
ant odor it is suitable for use on the face. The same 
authority advocates the use of turpentine locally. He 
uses the oleum pini sylvestris with sufficient oil of laven- 
der or essence of lemon to mask its odor. If used uncli- 



PSORIASIS. 541 

luted, the skin must be smeared with vaseline to prevent 
its cracking. It is better to use it diluted with olive oil, 
5j of oil of turpentine to ovij of olive oil, the proportion 
of the oil of turpentine being increased as the skin be- 
comes accustomed to it. The addition of oil of cade or 
oleum rusci to the mixture increases its efficacy. 

Salicylic acid, 5 to 20 per cent, strength, will remove 
the scales, and in some cases will prove curative. It is 
often a good plan to add it in 3 to 5 per cent, strength to 
our other ointments. The soap treatment, as described 
under chronic eczema, is of great value in some chronic 
circumscribed cases. Sulphur ointment, oleate of copper 
u rufigallic " acid, 10 per cent, in ointment, and resorcin, 
have all done well in some cases. Hydracetine anthra- 
robin, and aristol are among the latest remedies, but have 
not proved themselves as active as some of the older ones. 

Gallacetophenone in 5 to 10 per cent, strength as an 
ointment or dissolved in collodion may be tried, but is not 
as good as chrysarobin. 

Some patients have found benefit from the use of 
natural mineral waters at spas. It is possible that much 
of the benefit so obtained is from the prolonged and 
regulated bathing. Wearing rubber clothing next the 
skin, or with a fine piece of muslin between the rubber 
and the skin to avoid the production of eczema by the 
rubber, will soften and remove the scales, and hasten the 
disappearance of the patches. 

The Rontgen rays are useful to remove chronic 
obstinate patches. It is recommended to use a mod- 
erately soft tube with feeble light, to place the patient 
at from eight to fifteen inches from the target, and to 
expose him for three to six minutes, twice a week, for 
ten days or two weeks, and then suspend treatment. 
The lesions disappear in from three to six Aveeks. Hyde 
and Montgomery recommend sun-baths daily or several 
times a week. 

In psoriasis of the nails a 2 or 3 per cent, ointment of 
salicylic acid, pushed beneath the nail as far as possible, 



542 DISEASES OF THE SKIN. 

is a reliable remedy. The nails may be scraped thin and 
the finger ends wrapped up in the same ointment. 

Prognosis. A cure of psoriasis may be promised 
with a fair degree of certainty so far as the removal of 
the eruption then out is concerned ; but no promise can 
be made that the disease will not relapse. In this respect 
psoriasis resembles rheumatism and gout. While most 
relapses are readily removed in the course of a few weeks, 
in some cases one or more patches will be remarkably 
obstinate. 

Psorospermosis Follicularis Cutis. See Keratosis folli- 
cularis. 

Pterygium is simply an overgrowth of the normal nail- 
fold at the proximal end of the nail, so that it covers to a 
greater or less extent the lunula. It may be cut off. 

Purpura. Synonyms : Hsemorrhoea petechialis ; (Ger.) 
Blutfleckenkrau kheit. 

Symptoms. By this term is meant a hemorrhage into 
the skin which is not caused by direct traumatism. It is 
always readily recognized by the red, purple, or blue- 
black color of its lesions, which cannot be made to dis- 
appear by pressure. The hemorrhage may take place 
into any part of the skin ; into the subcutaneous tissues ; 
or into any of the glandular apparatus of the skin. It 
occurs with suddenness, and produces variously sized 
lesions to which certain names have been applied. When 
they are small, from pin-point size to perhaps an inch in 
diameter, they are called petechia?. When occurring in 
the form of more or less long streaks they are called 
vibices. Large bruise-like lesions with more or less 
swelling are eechymoses. Blood tumors of all sizes are 
ecchymomata or hcematomata. The color of all purpuric 
lesions depends upon their age. When first formed they 
are bright red, claret, or purple. Before disappearing 
they pass through various shades of color such as are 
seen after an ordinary bruise, becoming blue black, green- 
ish black, or brownish. These changes are due to the 



PURPURA. 543 

gradual absorption of the effused blood and the hsematin 
deposited from the blood globules. There is no definite 
time for complete absorption to take place, but eventually 
no trace is left of the previous hemorrhage. 

If the extravasation of blood takes place into the hair 
follicles, we will have papules formed. If between the 
layers of the epidermis, hemorrhagic bullae may result. 
Hemorrhage into sweat glands will give rise to hsemati- 
drosis. As complications of other dermatoses hemor- 
rhage may occur, as in urticaria, pemphigus, and eruptive 
fevers, but these should not be elevated into special 
varieties of purpura. 

There are five varieties of purpura, namely, purpura 
simplex, purpura senilis, purpura h senior rhagica, purpura 
rheumatica and Henoch's purpura. It is convenient for 
us to preserve these varieties for a time, though the 
results of the latest studies seem to indicate that the 
third variety is but a more developed form of the 
first, cases of simple purpura having been seen to run 
into the hemorrhagic form. By Crocker and others the 
third variety is regarded as a form of erythema exudati- 
vum. It, too, has been seen to run into the hemorrhagic 
form. 

Purpura Simplex is the most common variety, and 
usually takes the form of petechia?, the lesions being 
round or oval, or irregular in shape, or even circinate. 
Duhring describes a case of the circinate form, as does 
Stelwagon. 1 The lesions appear suddenly, generally with- 
out antecedent symptoms, and often at night. Like 
other varieties of purpura, the lower extremities are the 
most common seat of the eruption, especially their flexor 
aspects, but any part of the skin may be attacked, as also 
the mucous membranes. Crocker affirms that in children 
the lesions appear first upon the neck and upper part of 
the back. The lesions appear in crops, and most often 
are symmetrical. There may be but a single outbreak, 
and the whole disease may be at an end in a week or two. 

Vourn. Cutan. and Gen.-Urin. Dis., 1887, v., 369. 



544 DISEASES OF THE SKIN. 

But it may be prolonged for many weeks by a succession 
of outbreaks. There is usually no constitutional dis- 
turbance, or a slight rise of temperature and malaise, and 
the only things the patient complains of are the spots, and 
perhaps some itching. There may be lassitude, malaise, 
and slight elevation of temperature. Recovery is the rule. 

Purpura senilis is a form of purpura which occurs in 
persons about sixty-five years old who have senile skins. 
It occurs in red or telangiectatic hemorrhagic patches on 
the extensor aspects of the forearms, hands, legs, and 
feet, most often on the first two. It occurs spontane- 
ously and is unattended by subjective symptoms. The 
lesions may be single or multiple but always isolated and 
ungrouped. They begin as macules which coalesce to 
form the patches. These are bean sized, round or oval, 
irregular, more or less sharply defined. In eight to ten 
days they begin to fade, and disappear in the course of a 
few months (Pasini). 1 

Purpura Hemorrhagica. This form is also called 
morbus maculosus Werlhojfii, and land scurvy. It usually 
begins as such, and is heralded by pronounced ma- 
laise, rise of temperature, headache, and perhaps con- 
vulsions. It begins without prodromata. It differs 
from the previous variety in the more extensive hem- 
orrhages that take place, ecchymoses forming rather 
than petechia?, and in free bleeding from all the mucous 
membranes — nose, mouth, stomach, urethra, rectum, va- 
gina. These are so copious and uncontrollable at times 
that the patient will literally bleed to death in a few 
hours. Sudden death may also be caused by hemorrhage 
into the meninges and brain. An excellent study of this 
fulminating form of purpura has been made by Lock- 
wood. 2 In his case there was a rise of temperature to 
106.2° F. just before death, and the patient died in about 
sixty hours from the onset of the disease. He collected 
30 cases, in 13 of which the patients died from acute 

1 Monatsheft. f. prakt., Dermat., 1906, xliii., 451. 

2 Med. Rec, 1891, xxxix., 155. 



PURPURA. 545 

anaemia, internal hemorrhages, or septic infection, the 
shortest duration of any one case being seven hours ; in 8 
cases death was due to cerebral hemorrhage; and in 4 
cases the patients were pregnant. Happily all cases of 
hemorrhagic purpura are not fatal. In them the bleeding 
is moderate in amount, and the patient is gradually 
restored to health. Relapses may occur. 

Purpura Fulminans is the name applied to those very 
grave cases of purpura in which the patient dies in a 
short time. It is a form of purpura hsemorrhagica. It 
may affect several members of the same family, which 
suggests its infectious nature. It has followed scarlatina. 

Purpura Rheumatica. This is also called peliosis rheu- 
matica. It resembles purpura simplex in every way, 
excepting that the outbreak of the eruption is preceded or 
followed by pain in the joints accompanied by swelling, 
the malaise is more marked, and there is often rise of tem- 
perature. The eruption is frequently most abundant about 
the joints. The acute symptoms subside in two or three 
days, but relapses are frequent. True rheumatism may 
be present at the same time. Valvular heart lesions have 
been reported to occur after this variety of purpura, even 
without rheumatism. Rarely this variety may pass over 
into the hemorrhagic form. 

Henoch's Purpura, according to Osier, " is seen chiefly 
in children, and is characterized by relapses or recur- 
rences, often extending over several years ; by cutaneous 
lesions, which are those of erythema multiforme rather 
than simple purpura; by gastro-intestinal crises — pain, 
vomiting, and diarrhoea ; by joint pains or swelling, often 
trifling; and by hemorrhages from the mucous mem- 
branes. Any one or two of the above symptoms may be 
absent ; the intestinal crisis with enlargement of the spleen 
may be present and recur for months before the true 
nature of the trouble becomes manifest. The prognosis 
is, as a rule, good." 

Etiology. Purpura may occur at any period of life, 
in both sexes, and in the most varying conditions of health. 
35 



546 DISEASES OE THE SKIN. 

There is no doubt that it occurs as a symptom in different 
diseases and cachexias ; after the ingestion of certain drugs, 
and under other circumstances too numerous to catalogue 
here. To permit the escape of blood one or both of two 
things have occurred, namely, a change of the blood itself 
that allows of its passing through the walls of the vessels, 
or a change in the vessel walls themselves that permits the 
blood to pass through them. Purpura has been noted after 
the loosening of some artificial support to a part of the 
body, such as a tight bandage worn for a long time. 
It occurs not infrequently in old age. In both these 
conditions it is due to a weakening of the tone of the 
vessel. In the former case matters right themselves in 
a few days — a happy conclusion that cannot be anticipated 
in the latter case. Weakness of vascular walls may also 
be the cause of those somewhat rare cases of purpura 
without cachexia seen in infants. Other cases of purpura 
are due to small thrombi lodging in the smaller vessels. 
Some cases seem to be due to vasomotor or trophic nerve 
action causing either sudden alterations in the calibre ot 
the vessels or degenerations in their walls. Recurring 
purpura has been noted about the point of greatest pain 
in neuralgia. 

The microbian and infectious origin of purpura has its 
advocates. Some authorities believe that purpura occur- 
ring in an infectious disease is due to microorganisms. 
Letzerich 1 published a brochure on this subject in 1889, 
in which he described the "bacillus purpura? hsemor- 
rhagicae Letzerich " as the cause of the disease. This 
has sharp angles and edges, is readily cultivable, and 
pure cultures injected into rabbits give rise to hemor- 
rhages either spontaneously or on slight trauma. His 
findings have been confirmed by others. There is a 
growing belief in the theory of auto-intoxication as a 
cause of some of the cases. 

Pathology. It is in the corium that the hemorrhages 
chiefly occur, but the subcutaneous tissues are sometimes 

iMonatshefte f. prakt. Dermat., 1889, ix., 312. 



PURPURA. 547 

implicated. Examination of the blood shows irregular 
changes in the number of blood cells and in their form, as 
well as in the quantity of fibrin. 

Diagnosis. The diagnosis of purpura is easily made. 
No other disease produces bright-red, slightly elevated 
lesions, the color of which cannot be made to disappear 
under pressure. From flea-bites they are distinguishable 
by the absence of a central punctum. Purpura hsemor- 
rhagica bears a close resemblance to scurvy, but in the 
latter a dietary deficient in vegetables is a marked etio- 
logical factor ; there are also greater prostration, swelling 
of the gums, loosening of the teeth, and brawny swelling 
of the limbs. It is possible that further investigations of 
scurvy may show that it is but a form of purpura 
hemorrhagica that has been modified by diet. 

Tkeatment. In simple purpura there is not much to 
be done except to put the patient in as good a hygienic 
condition as possible, give proper attention to any cachexia, 
and relieve symptoms. In peliosis rheumatica and pur- 
pura hemorrhagica the patient should be kept abso- 
lutely quiet in bed, his diet should be of the most nutri- 
tious and easily assimilable kind, and ergot and iron ad- 
ministered. Calcium chlorid, 15 to 30 grains t. i. d. has 
been advised by Wright to increase the coagulability of 
the blood. It must be discontinued after a few days. 
Of course, if there is hemorrhage from the nose, vagina, 
or other mucous cavity, an effort must be made to stop 
the flow by means of a tampon, ice, hot water, or any 
method that experience has proved useful. Ergotin may 
be employed hypodermically ; and turpentine ; dilute 
sulphuric acid ; nitrate of silver in pill-form, J to ^ of a 
grain three times a day ; and other astringents have been 
found useful. Letzerich recommends for the local treat- 
ment of bleeding from the gums — 

JJ. Tinct. ratanhiae, 10 parts 

Tinct. iodini, 5 " M. 

of which 10 drops are to be taken in a wineglassful of 
water. For this purpose other astringents, as tannin, 



548 DISEASES OF THE SKIN. 

alum, and the like, may be used. Adrenalin should be 
tried in purpura hemorrhagica. 

Prognosis. From the beginning of a case it is not 
possible to say how it will turn out, purpura simplex some- 
times changing to the hemorrhagic form. We should, 
therefore, be very guarded in our prognosis. Most cases 
met with terminate favorably. Some apparently des- 
perate cases recover. 

Pustula Maligna. Synonyms : Anthrax ; Malignant 
pustule ; (Fr.) Charbon. 

This is a disease of cattle, sheep, and horses, in which 
it is called splenic fever, and is due to local inoculation 
with the bacillus anthrax, often through the agency of 
flies. If the bacillus gains access to the internal organism, 
it produces a rapidly fatal general disease with no skin 
lesion. In the human the exposed parts — face, hands, 
and neck — are the most frequent sites of the disease. In 
a day or two after inoculation the patient notices a burn- 
ing or itching of the affected part and the formation of a 
livid-red papule upon which a bulla or pustule soon forms. 
This ruptures, the red spot changes into a black gangren- 
ous eschar, the parts around it become indurated, oedema- 
tous, of dusky-red hue, and studded with small vesicles 
or pustules. There are marked involvement of the lym- 
phatics and enlargement of the neighboring glands, that 
may suppurate. In favorable cases the slough separates 
and healing by granulation takes place. In fatal cases 
the gangrenous process extends rapidly, symptoms of sep- 
tic infection declare themselves, and the patient succumbs 
to the disease in from two to eight days. In all cases 
there is more or less constitutional disturbance. 

Diagnosis. The diagnosis of malignant pustule is 
made mainly by the rapidity with which the disease de- 
velops ; the presence of the gangrenous patch with the 
hard indurated tissues about it ; and the severity of the 
constitutional symptoms. The finding of the bacillus will 
verify the diagnosis. 

Treatment. The total excision of the diseased patch 



BHINOSCLEROMA. 549 

by means of a free incision is the most radical and effec- 
tual treatment for the disease. The injection of iodine or 
of a 5 per cent, solution of carbolic acid under the eschar 
is a good method of treatment. The hyposulphite or sul- 
phite of soda, and large doses of quinine, are worthy of 
trial. 

Quinquad's Disease. See Folliculitis decalvans. 
Radesyge. See Lepra. 

Radiodermatitis. See Dermatitis from #-rays. 
Raynaud's Disease. See Dermatitis gangrenosa. 
Recklinghausen's Disease. See Fibroma. 

Red Gum. "An obsolete term for various transitory 
eruptions in teething children." (Foster.) Commonly 
this is malaria rubra. 

Rhinophyma is the term used to designate that form of 
hypertrophic rosacea in which pendulous tumors develop 
on the nose. These may attain to so great a size that 
they hang down over the mouth. See under Rosacea. 

Rhine-scleroma. Synonyms : (Fr.) Rhinosclerome ; (Ital.) 
Binoscleroma ; Perisarcoma. 

Symptoms. This is an exceedingly rare form of dis- 
ease that was first described by Hebra and Kaposi. It 
affects almost exclusively the nose and its mucous mem- 
brane, and assumes the form of flat or slightly raised, 
sharply defined, isolated or confluent, very hard, lobulated, 
elastic plates, tumors, or nodes which are painful on pres- 
sure. These lesions are located in the skin or mucous 
membrane of the septum of the nose, or in the alse nasi 
and the neighboring parts of the upper lip. They can be 
raised from the underlying parts, but the skin is so infil- 
trated that it can move only with the growths. The 
color of the skin may be normal, or bright or dark 
brownish red. It may look like a keloid or hypertro- 
phied scar. The contiguous skin shows no abnormalities 
whatsoever. The epidermis over the growths often shows 



550 



DISEASES OF THE SKIN. 



rhagades, from which exude a viscid secretion which dries 
into yellowish adherent scabs. 

The disease begins as a thickening and hardening of 
the septum of one or both alse without inflammatory re- 
action or pain. Slowly the nose becomes deformed, broad, 
and flat, and at last by progressive thickening of both 
septum and alse the nostrils become occluded. The pro- 
cess may involve the lips so that the opening of the 

Fig. 75. 




Rhinoscleroma. 



mouth becomes greatly lessened, and may affect the gums. 
More frequently it proceeds backward along the nostrils 
on to the velum palati. The growth shows little tend- 
ency to ulceration or retrograde metamorphosis. At the 
most superficial parts excoriations occur. Late in the 
disease the teeth may loosen and fall out, and the gums 
may atrophy. The disease begins in some cases in the 
pharyngeal vault. The epiglottis and larynx may be in- 
volved in the process, and aphonia, and suffocative or epi- 
leptic-like attacks may occur. There is no constitutional 
disturbance, and the only subjective symptoms are those 
of discomfort on account of the interference with respira- 



RINGSKURV. 551 

tiou. The disease is steadily progressive, shows do ten- 
dency to recovery, and recurs rapidly when the diseased 
parts are cut away. 

Etiology and Pathology. It occurs in all social 
grades, and affects both sexes with about equal frequency. 
It usually begins between the fifteenth and fortieth years. 
It is most frequent in warm climates, and is specially 
prevalent in Austria and Russia. A bacillus has been 
found in the tissues by Frisch that is regarded as the 
cause of the disease. It is described as short, thick, 
ovoid, capsulated, in free groups and in cells. It is named 
bacillus rhinoscleromatis. The disease is a granuloma, 
the corium and papillary layers being densely infiltrated 
with small cells. In places there is very dense fibrous 
tissue. There is hardly any change in the epidermis. 

Diagnosis. The location upon the nose and upper lip 
alone, the ivory hardness of the growths, and their pro- 
gressive course without tendency to ulceration or soften- 
ing, will establish the diagnosis as against syphilis, epithe- 
lioma, and sarcoma. Keloid rarely occurs upon the nose, 
and never runs the characteristic course of rhinoscleroma. 

Treatment. Treatment is very unsatisfactory. The 
growths may be excised or curetted away, but neither 
process will assure against a relapse. The nostrils may be 
kept open by means of sponge-tents, and the like. Bes- 
nier 1 recommends boring into the tissues with points of 
chloride of zinc for the purpose of giving passage to air. 
Pyrogallic acid, 10 per cent, in vaseline, has been recom- 
mended as of value. Lustgarten has treated one case 
with excellent result by the arrays. 

Prognosis. The prognosis is bad. The disease is 
progressive, and threatens life by suffocation on account 
of involving the larynx. 

Rhus-poisoning. See Dermatitis venenata. 
Ringed Hair. See Canities. 
Ringskurv. See Trichophytosis. 

1 Ann. de derm, et de syph., 1891, ii., 603. 



552 DISEASES OF THE SKIN. 

Ringworm. See Trichophytosis. 
Rissopola Lombarda. See Pellagra. 
Hitter's Disease. See Dermatitis exfoliativa neonato- 
rum. 

Rodent Ulcer. See Epithelioma. 

Rosacea. Synonyms : Acne rosacea ; Gutta rosacea seu 
rosea ; Acne erythematosa ; (Fr.) Acne rosee, Couperose, 
Rosacee ; Ros6e ; (Ger.) Kupferrose, Kupferfinne, Kup- 
frigegesicht. 

A chronic disease ot the skin, limited in most cases to 
the middle third of the face from above downward, and 
characterized by a diffused or patchy redness made up of 
dilated capillaries. 

This disease is very commonly called acne rosacea, but 
inasmuch as the papules that ofteu occur with the disease 
are not true acne pustules it is best to drop the " acne " 
from its title. 

Symptoms. Rosacea is one of the more common skin 
diseases, and is peculiar in affectiug, with few exceptions, 
only the middle third of the long diameter of the face — the 
forehead, nose, and adjacent portions of the cheeks, and 
the chin. The nose may be affected alone, and in many 
cases the forehead escapes entirely. The disease has three 
forms or stages. The first consists in a simple redness of 
the affected skin with more or less well-marked dilatation 
of the capillaries. In the second stage there is an added 
element of superficial papules and pustules, and perhaps 
nodules. In the third stage there is marked hypertrophy 
of the skin. The process may stop at any stage. An oily 
seborrhoea may complicate the disease, Unna even claim- 
ing that his seborrheal eczema is the first stage of all cases 
of rosacea. 

The first stage varies in degree. At first there may be 
faint flushing of the skin, as after the ingestion of hot 
fluids, exposure to cold, and the like. This being re- 
peated, permanent dilatation of the capillaries takes place. 
The dilated capillaries are not evident all over the patch. 



ROSACEA. 



553 



The greater part of the patch may present an even red- 
ness. The border of the patch is ill defined, and no 
matter how fiery red the color may be the skin feels cool 
to the touch. This is because the congestion is passive on 
account of a sluggish circulation. In some cases, however, 
there may be but little general redness, only a number of 
dilated capillaries. These telangiectases are best seen on 
the nose. In some cases there may develop a congestive 
seborrhoea or even an erythematous eczema, which, yield- 



FlG. 




Rhinophyma. (Lassar.) 



ing to appropriate remedies, leaves behind an undoubted 
rosacea. 

The second stage may develop from the first after the 
latter has lasted a considerable length of time, or be almost 
coincident with it. The number of papules and pustules 
may be considerable, and the tubercles large. If so, the 
amount of redness will be great. The peculiar feature of 
the pustules is their superficiality. They are usually quite 
small, say of pinhead size, and when pricked give exit to 
but a small drop of thin pus. The tubercles are enlarged 



554 DISEASES OF THE SKIN. 

or clogged sebaceous glands, but all these lesions are but 
secondary to the chronic, hyperemia, and not primary, as 
in acne. There may also be comedones and true acne 
scattered over the face. 

While the majority of cases never go beyond the second 
stage, in some cases the continued and excessive hyper- 
emia leads to an increase of connective tissue, and the 
nose, tip and sides, becomes converted into a lobulated mass 
of tissue, sometimes so great as to form pendulous tumors 
hanging down over the mouth. This last condition is 
known as rhinophyma. The whole nose is of deep-red or 
purple color, and studded over with crater-like openings, 
leading down into the thickened mass. At times ulcer- 
ation occurs in these crypts and causes additional annoy- 
ance and deformity from destruction of tissue. 

While in the vast majority of cases the middle third of 
the face alone is affected, in some cases the whole face be- 
comes red, and the redness may extend down upon the 
neck. Rosacea is seen at times on the scalp of bald- 
headed persons just above the forehead. 

Etiology. The cause of the disease is probably a 
vasomotor reflex neurosis. Schwimmer regards it as a 
tropho-neurosis ; Unna, as a seborrhoeal dermatitis. It 
occurs in adult life, most frequently after the twenty-fifth 
or thirtieth year, though it may occur even at puberty. 
There is no connection between it and acne. While many 
patients will tell you that they had " pimples " when 
young, as many will inform you that they have always had 
a good complexion until the rosacea began. Women are 
more frequently affected than men. Digestive disturb- 
ances are a very common cause of the disease, and the 
trouble may be located either in the stomach, intestines, 
or accessory digestive organs. Drinking of alcoholics 
will undoubledly cause it, on account of producing both 
gastric catarrh and reflex dilatation of the facial vessels. 
The inordinate use of strong tea acts in the same way, 
and probably gives rise to as many cases as does alcohol. 
Exposure to the weather or to extremes of temperature 



ROSACEA. 555 

will cause rosacea without digestive disturbances, but 
when combined with the latter leads on to the most bril- 
liant examples of it. Constipation, menstrual derange- 
ments, anaemia, chlorosis, gout, lithsemia, the menopause, 
each one has been noted in connection with rosacea. The 
use of cosmetics has been followed by it. Various mor- 
bid conditions of the mucous membrane of the nose have 
been found in connection with it. Tight lacing is fre- 
quently followed by rosacea. 

Pathology. In the first stage there is dilatation of 
the bloodvessels in the cutis. In the second stage this is 
more pronounced, and the corium is slightly thickened 
and oedematous in places. In the third stage there is in 
addition enormous hyperplasia of the connective-tissue 
elements of the cutis, and the sebaceous glands are en- 
larged. (Elliot.) 

Diagnosis. When we meet with a case of redness of 
the skin, with or without papules, pustules, or tubercles, 
that is limited to the middle third of the vertical diameter 
of the face, it is probably one of rosacea. It differs from 
acne in its limited area, the superficial character of the 
pustules, the absence of comedones, and the capillary dila- 
tation. Lupus erythematosus may occur in the same loca- 
tion, but in it we do not find the dilated capillaries ; but 
we do find thickening of the skin, adherent scales with 
prolongations from their under side, a sharply denned, 
slightly raised border to the patches, and, if the disease 
has lasted any time, more or less delicate cicatricial tissue. 
In its early stage the diagnosis is not always easy. Lupus 
vulgaris should not confuse us, as in rosacea there is an 
entire absence of the characteristic apple-jelly-like tuber- 
cles of lupus. The tubercular syphilide may resemble 
rosacea in its second or third stage, but soon it undergoes 
softening and ulceration — processes that do not occur in. 
rosacea. Moreover, it is not symmetrical, but occurs in 
the form of groups of tubercles, presents no telangiectases, 
and evidences of other syphilides are usually to be found. 
Erythematous eczema burns and itches, the skin is some- 



556 DISEASES OF THE SKIN. 

what swollen and scaly, and feels harsh and leathery. 
Sometimes an eczematous condition complicates a rosacea, 
and the latter declares itself only when the former is 
cured. 

Treatment. In order to treat rosacea successfully we 
must first endeavor to remove the cause. We must in- 
quire as to the condition of the digestive apparatus, the 
manner in which menstruation is performed, exposure to 
heat and cold, and, in fact, ascertain the patient's general 
condition. Then we must address ourselves to the regu- 
lation of any deranged function. We must stop the use 
of alcoholics in any form, and the ingestion of all hot 
fluids, such as tea, coffee and soup. All these tend to 
produce dilatation of the bloodvessels of the face and to 
keep up those conditions we wish to remove. The 
patient's diet should be carefully regulated, and such 
things as pastry aud sweets cut off, so as to make diges- 
tion as easy as possible. Medicinally, tincture of nux vom- 
ica, the mineral acids, or alkalies are to be administered 
q. r. n. Nux vomica has often seemed to render good 
service, even without there being marked digestive dis- 
turbance. The drinking of a J pint of hot water before 
meals is to be advised. Salol is a good remedy in many 
cases of intestinal fermentation. Ergot or ergotin proves 
useful in some cases, either with or without uterine dis- 
turbances. Ichthyol is commended by Unna. The am- 
monia-sulphate is the preparation he advises, and it is 
best given in capsules to cover the taste. The dose is 3 
drops two or three times a day. Ichthalbin, 1 5 grains t. 
i. d., has been substituted for ichthyol, and some good re- 
sults from its use have been reported. Whitfield advises 
the administration of 1 to 2 grains of menthol after meals, 
or J drachm of syrup of codeia in a wineglass full of water 
before meals. 

The local treatment is important in hastening a cure, 
but is not of itself curative in well-marked cases of reflex 
rosacea. The patient must be instructed to protect the 
skin from the action of wind and weather, by either ap- 



ROSACEA. 557 

plying some ointment, such as cold cream, or a lotion, 
such as the calamin lotion, or a powder, such as corn- 
starch, before venturing out of doors. The face should 
be bathed with hot water every night before going to bed, 
the water being as hot as the skin can stand without burn- 
ing, and it should be sopped on for about ten minutes, 
fresh supplies of hot water being added from time to time 
so as to maintain a uniform temperature. This is benefi- 
cial because the primary dilatation of the vessels caused 
by it is followed by contraction. After the bathing the 
following lotion should be applied : 

& Zinc, sulphat., \ __ 

Potass, sulphuret., J aa 3j 5 aa 4 

Aquae rosae, ad ^iv., ad 120 M. 

It is, perhaps, as good as any application we can make. 

Van Harlingen gives another good one as follows 

li Sulphur, praecipitat., 3 j ; 12 

Pulv. camphorae, gr. v ; 1 

Pulv. tragacanth., gr. x ; 2 

Aquae rosae, j - ~ m 

Liq. calcis, J 5J ' M. 



Instead of lotions, sulphur ointment (5j-oj) or the 
white precipitate ointment may be used, or simply pow- 
dered sulphur. In obstinate cases Vleminckx's solution 
may be used. It is composed as follows : 



R Calcis, 


3iv; 


15 


Sulphur, sublimat., 


5J; 


30 


Aquae destillat., 


l*\ 


300| 



M. 

Boil together with constant stirring, until the mixture 
measures 6 fluid ounces, then filter. This is to be diluted 
four or five times at first, and used at night only, fol- 
lowed by cold cream in the morning. The dilution is to be 
lessened by degrees. Hillairet 1 recommends washing the 
face in the morning with hot water, followed by a solu- 
tion of oxide of zinc, 3 or 4 grains to the ounce, sopped 

1 Progres med., 1880, viii., 182, 



558 DISEASES OF THE SKIN. 

on for half an nour. Before going to bed the following 
is to be applied to the face : 



R 



Alcohol, camphorat., 


gii-iiiss ; 


8 ad 15 


Sulphur, sublimat., 


3j; 


30 


Aquae destillat., 


ad 5viij ; 


ad 250 



M. 



After six days this is to be discontinued for a couple of 
days, and then begun again. 

Any of these remedies may produce a dermatitis, fol- 
lowed by desquamation, which is to be desired. For this 
purpose we may use resorcin, 10 to 20 per cent, in water, 
alcohol, or vaseline, stopping it as soon as the skin begins 
to peel, when the skin is to be dressed with cold cream 
until the irritation has subsided. Then the resorcin is to 
be used again. 

lehthyol, in 5 to 50 per cent, strength in aqueous 
solution, has been highly extolled by Unna and others, as 
well for external as for internal use. W. J. Munro x 
recommends painting the nose, after bathing with hot 
water, with a solution of adrenalin, made by dissolving 
one of Borroughs & Welcome's tablets in 1 drachm of 
water with a little camphor. This first causes redness, 
followed in five minutes by paleness. During the day 
the lotio alba is to be used ; and from 2 to 6 of the tab- 
lets of adrenalin are to be taken by the mouth, stopping 
them if vertigo or nausea is caused. 

G. W. Wende 2 reports a cure by using galvanism, 
placing the anode over the abdomen and the cathode on 
the face. 

If the case is highly inflammatory when first seen, our 
first attempts should be in the direction of reducing the 
inflammation by means of soothing ointments. After a 
few days we can begin the treatment of the rosacea. 

Surgical procedures are necessary to hasten the removal 
of pustules, and to destroy dilated vessels and hypertro- 
phic tissue. Pustules are quickest removed by the 

1 Antral. Med. Gaz., 1900, xix., 496. 

2 Buffalo Med, Journ., 1898-9, xxxviii., 254. 



ROSACEA. 559 

curette, as in acne. Dilated vessels are best destroyed 
by electrolysis with the electric needle attached to the 
negative pole, introducing it perpendicularly into the 
vessel at one or more points of its course, or longi- 
tudinally in its course, and letting it remain for a few 
seconds until the vessel appears as a white line, The 
method of using electrolysis is more fully described un- 
der hypertrichosis. It is often necessary to repeat the 
operation several times before the vessel is destroyed. 
The operation is prone to leave punctate scars. The 
thermo-cautery may also be used in the same way. Mul- 
tiple scarification is most useful in reducing red patches. 
It may be done by means of a scalpel, making parallel 
lines near together and through the skin, and then a 
second series over these ; or a multiple scarifying-knife, 
as sold in the shops, may be used for the purpose. H. 
Fournier : advises the use of a flat needle rounded at its 
end and bevelled on its under side. The vessels are to 
be cut obliquely to their long axis, while the skin is put 
on the stretch. After scarifying, bleeding should be en- 
couraged for a few moments by the application of hot 
water. Then the surface should be swabbed over with 
a solution of carbolic acid, 2 drachms to the ounce of 
glycerin and water. This will check the bleeding and 
constringe the vessels. No after-treatment is needed, as 
a rule. If reaction tends to go too far, a soothing oint- 
ment may be applied. The operation should be repeated 
once every week or two. Multiple punctures may be 
made with the acne lancet, the subsequent treatment being 
the same as after multiple scarifications. It is astonish- 
ing to see how rapidly the redness will be reduced in 
many cases, and this without deformity being caused. 
Multiple scarifications may be employed for the reduction 
of tuber culated masses — rhinophyma — but a plastic op- 
eration is the most satisfactory method of treatment. 
Both the high frequency current by sparking and the 
Rbntgen rays have been used with benefit. The latter 
1 Journ. mal. cut., etc., 1895, vii., 257, 



560 DISEASES OF THE SKIN. 

clear up the acne element and reduce the connective tis- 
sue overgrowth, but will not remove the dilated vessels. 
Prognosis. In cases of rosacea arising from expos- 
ure to weather in drivers and sailors, and in those fol- 
lowing similar pursuits, we cannot expect to effect a cure, 
as the patients cannot do the one thing necessary — give 
up their occupations. In most all other cases we can 
promise great amelioration of the annoying redness, and 
in many we can effect a cure ; but we had best not at- 
tempt to treat a patient who will not follow our directions 
as to diet and hygiene. 

Rose. See Erysipelas. 

Rosee. See Rosacea. 

Rose Rash. See Erythema. 

Roseola. See Erythema roseola. 

Roseola Pityriaca. See Pityriasis rosea. ' 

Roseola Syphilitica. See Macular syphilide. 

Roseola Scuiameuse. See Pityriasis rosea. 

Rotheln, Rubella, or German measles, is a mild con- 
tagious disease that resembles measles, but differs from it 
in the mildness of all its symptoms, in the lighter color 
and smaller size of its lesions and in the absence of the 
crescentic arrangement of them. It is seen mostly in 
children. Its period of incubation is two or three weeks. 
Like measles, it may be mistaken for either an erythema 
or an erythematous syphilide, and its diagnosis is along 
the same lines as is that of measles, which see. It is 
not so blotchy as measles, the lesions being pale red, 
macular or maculo- papular varying in size from a pin- 
head to a lentil, and the catarrhal symptoms are absent 
or but slight. Swelling of the glands of the neck is a 
symptom that may or may not be present, but when 
present is characteristic. Febrile movement is slight. 
The lesions may take the form of small papules, and 
assume rather a brownish than a red color. The erup- 
tion is often itchy, and the lesions may occur on the mu- 
cous membranes. The eruption disappears in a few days. 



SARCOMA. 561 

Desquamation may occur. It differs from scarlatina in 
the mildness of all its symptoms, and in the absence of 
the diffuse scarlet eruption of the latter disease. The 
treatment is purely symptomatic. 

Rothlauf. See Erysipelas. 

Rotz. See Equinia. 

Rupia. See Syphilis. 

Rupia Escharotica. See Dermatitis gangrenosa infantum. 

St. Anthony's Fire. See Erysipelas. 

Salt-rheum. See Eczema. 

Salzfluss. See Eczema. 

Sarcocele of the Egyptians. See Elephantiasis. 

Sarcoid, Multiple Benign. This is described by C. 
Boeck, as an eruption of hemp- to bean-sized, firm nodules 
on the head, the extensor surfaces of the extremities, and 
the trunk. Their appearance is preceded by periodical 
swelling of the cervical and axillary glands. The disease is 
symmetrical. On the scalp there may be yellowish patches. 
The nodules are at first bright red, later yellowish or 
brown. There is some scaling. They tend to spread 
peripherally, to have a central depression, and to ar- 
range themselves in diffuse patches or segments of circles. 
Eventually they disappear, leaving a white or yellow scar. 
The areas of new growth consist of perivascular masses 
of sarcomatoid tissue composed of rapidly proliferating 
epithelioid cells in the perivascular lymph spaces. As 
the tumor cells degenerate, a net work of branching 
and anastomosing connective tissue cells becomes visible. 
True giant cells of sarcomatous type are rarely found. 
The disease seems to be benign, and to be cured by arsenic. 

Sarcoma. We are here interested in sarcoma of the 
skin alone. Sarcomas may be primary in the skin, but 
most often they are secondary. They form variously sized 
tumors, but tend to run a malignant course, multiplying 
more or less rapidly, breaking down, affecting internal 
organs by metastasis, and killing the patient in a few 
months or years. There are three types of sarcoma, 



562 DISEASES OF THE SKIN. 

namely, the round-cell sarcoma, the small-cell sarcoma, 
and the melano- or pigment sarcoma. Very commonly 
sarcomata are of mixed type ; or sarcomata may be divided 
into two varieties — the pigmented and the non-pigmented. 

According to Brocq, 1 who, following Perrin, has made 
an exhaustive study of the disease, primary melanotic sar- 
coma originates frequently from an irritated nsevus or 
other pigmented lesion, but may occur independently. At 
first it is always single and small. It tends to enlarge 
and attain the size of a nut. In shape it is oval or spher- 
ical. It is nearly always sessile. Its color is dark blue 
or black. It is very hard to the touch. It may remain 
stationary for a long time, but in course of time new 
tumors will appear, either about the original one or at 
distant points by way of the lymphatics. Some of the 
original tumors will disappear, while new ones appear ; 
some will break down and form, irregular ulcers whose 
floors are black and uneven, and secrete a thick, melanotic 
liquid, or a little pus, or almost solid black matter. A 
large lobulated mass may be formed by the coalescence of 
a number of smaller lesions. The viscera become in- 
volved, and death soon occurs. 

A rare form of melauotic sarcoma is described by Hutch- 
inson as melanotic whitlow, which at first is a chronic ony- 
chitis, the border of which looks like a lunar-caustic stain. 
It very gradually develops into a fungating tumor, slightly 
pigmented. The nail is shed, and generalization occurs 
(Crocker). 

Non-pigmented primary sarcoma may be generalized or 
localized. The generalized form begins usually upon the 
extremities, and causes upon the hands and feet a peculiar 
hard oedema, accompanied by tension of the skin, and per- 
haps itching or pricking. It may begin as brownish-red, 
livid, purple, or blue patches, upon which pinhead-sized 
nodules appear, which gradually enlarge. In some cases 
little, infiltrated, isolated, blue or reddish-brown nodes 
will form. Sometimes the first appearance will be a dif- 
i Th§se de Paris, 1885. 



SARCOMA. 563 

fused cyanotic patch, which later will become a bossy 
elevated patch. When the disease is fully developed the 
hands and feet are thick, deformed, infiltrated, as firm as 
cartilage, brown or blue with a red tint. The skin is 
glossy, scaly, uneven. The nodes may be raised, pedun- 
culated, or ulcerated. Similar lesions are found upon the 
rest of the body, though rarely on the trunk. They may 
remain stationary, disappear, fall off, multiply, ulcerate, or, 
finally, involve the mucous membranes, and cause death. 

The localized form develops ordinarily from an irritated 
nsevus, and is most often encountered on the extremities. 
It forms a hard, wrinkled tumor, which may ulcerate. Its 
color is usually that of the normal skin, though it may be 
red. It may grow to be the size of an orange or take on a 
mushroom-like form. It may not generalize for a long 
time, or it may do so spontaneously or after an attempt at 
removal. 

To this class of tumors Hutchinson's recurrent fibroid 
of the shin belongs. As described by him, " it begins 
usually on the lower extremities, grows slowly at first, but 
recurs rapidly and persistently after removal, however 
wide the incision, and ultimately generalizes, fungates, 
forms blood cysts, and destroys the patient." 

Sarcomas are very vascular, and are subject to profuse 
hemorrhage when injured or when they ulcerate. 

Under the name of idiopathic multiple hemorrhagic sar- 
coma a disease was first described by Kaposi. It occurs 
in adults, and begins as an oedenia of the hands, feet, and 
face, with more or less pruritus. Later dark-blue or 
purplish spots appear deep in the skin, which after a time 
form raised nodules, which may be sessile or pedunculated, 
but are always dark blue or purple. They vary in size up 
to a cherry or larger, or may be isolated or grouped. 
They are tender, and the patient may experience more or 
less pain. The extremities or face become elephantiasic in 
appearance, and covered with scales, and more or less 
rugous. The tumors may remain for a long time or dis- 
appear, or, rarely, ulcerate. The color of the tumors is 



564 



DISEASES OF THE SKIN. 



due to vascular development. The disease is chronic in 
its course, and may last for fifteen or twenty years without 
affecting the patient's health, or the patient may die after 
a few years by extension of the disease and the involve- 
ment of the mucous membranes. The disease may extend 
up the limbs to the trunk. Recovery may take place. 





Fig. 


77. 


















' ""'% 




■ ■-■"'"'>. ■ 










jP"\ 


w 




1 T* W 




f r 


m 

Wl;fM 




V 










^HK Si 










3& . m 

Ml 












**e 


''-',: : m 





Multiple idiopathic heemorrhagic Sarcoma. 

Etiology. We know very little in regard to the eti- 
ology of sarcoma. It occurs at all ages, some of the most 
malignant cases being seen in childhood. Brocq says that 
the localized non-pigmented sarcoma is most frequent in 
women, and that the generalized form is most frequent in 
robust men of forty to sixty years. Piffard gives the ages 
at which they are most prone to occur as before the fifteenth 
and after the forty-fifth year. The Kaposi type is most 



SARCOMA. 565 

often seen in men. It is possible that all types may be 
due to infection, but the pathology of the disease is ob- 
scure. 

Pathology. Sarcomas of the skin are histologically 
identical with sarcomas of deeper parts. They are 
connective tissue tumors in which the cellular elements 
greatly predominate in bulk over the intercellular sub- 
stance. In this respect the tumors are comparable to 
embryonic connective tissue. The structure and form of 
the cells differ in different sarcomas, and the intercellular 
substance may be very scanty and of delicate structure 
in one tumor, and in another approach in quantity and 
appearance the frame work of normally developed con- 
nective tissue. It is from these variations in the cells and 
intercellular substance that the tumors are numerously 
classified as simple sarcomas including the spindle and 
small and large round-celled sarcomas, and the lympho- 
and fibrosarcomas ; organized sarcomas including the 
alveolar sarcomas or endotheliomas, and the angiosarco- 
mas ; and lastly those sarcomas characterized by secondary 
changes in the cells or ground substance, among which 
the form of greatest dermatological importance is the 
melanosarcoma. In any of these the usual various retro- 
gressive changes may occur, such as fatty, colloid, or 
hemorrhagic degeneration, caseation, necrosis, ulceration, 
etc. 

Melanotic sarcomas are vascular small or large round- 
celled, or more often spindle-celled tumors, with sometimes 
a giant cell here and there, and characterized by the pres- 
ence of abundant • intra- and intercellular, granular and 
diffuse pigmentation. It has been recently demonstrated 
that many malignant pigmented tumors, arising from pig- 
mented moles and naevi, and formerly classed as melanotic 
sarcomas, are in reality carcinomas. 

In idiopathic multiple hemorrhagic sarcoma the cells 
are round or fusiform, and there is a rich network of vas- 
cular sinuses and thin-walled bloodvessels. Hemorrhagic 
areas are scattered throughout the growth, and deposits 



566 DISEASES OF THE SKIN. 

of pigment derived from the extravasated blood. All 
the pigmentation is due entirely to the capillary hemor- 
rhages. Involution, when it occurs, is through destruc- 
tion and resorbtion of the tumor cells and pigment, with 
concomitant connective tissue organization. 

Diagnosis. The diagnosis of sacoma is generally easy, 
but at times it is difficult. The pigmented forms are 
usually readily recognizable by their color. The non- 
pigmented single sarcoma may be distinguished from 
epithelioma by its feel, which, though firm, lacks the hard- 
ness that is characteristic of cancer. Fibromata are not so 
firm as are sarcomata, are more commonly pedunculated, 
and show no tendency to degenerative changes. Mycosis 
fungo'ides has a primary eczematous stage ; its tumors are 
of a brighter red, and they come and go, and undergo 
various changes much more rapidly than do sarcomata. 

Treatment. Excision of a single non-pigmented sar- 
coma is often curative. In multiple sarcomata, and in the 
melanotic variety, operative interference is usually not 
only not curative, but has often seemed to hasten general- 
ization. Kobner and others have used hypodermic in- 
jections of arsenic with brilliant results in some cases. 
Kobner used Fowler's solution of half strength, and in- 
jected 2 J to 4 drops of it once a day. After three months 
the dose was increased to 7 J, and then to 9 drops. Others 
have tried arsenic without affecting a cure. Still it is 
worthy of trial, as it may cure the disease if it is well 
borne by the patient. Inoculation by the toxin of the 
streptococcus has cured some cases, but its use is not with- 
out danger to the life of the patient. The Rontgen rays 
will cause the disappearance of the tumors in some cases, 
but they are prone to relapse. 

Prognosis. This is always grave. The course of the 
disease is nearly always from bad to worse, though the 
fatal result may not be reached for many years. Melanotic 
sarcoma is more rapidly fatal than is the ordinary form. 

Satyriasis. See Lepra. 



SCABIES. 567 

Scabies, Synonyms: The Itch; (Fr.) Gale; (Gr.) 
Kratze. A contagious disease of the skin due to its inva- 
sion by the acarus scabiei, and characterized by excessive 
itching, worse at night, and by excoriated lesions, pustules, 
and cuniculi upon the anterior face of the wrists, between 
the fingers, on the breast of females, the penis of males, 
and about the umbilicus of both sexes. 

Symptoms. The popular name of scabies, which is the 
Itch, gives us at once one of the marked features of the 
disease. Itching is always present in it. While it may 
be somewhat in abeyance during the day, it is hardly ever 
absent, and at night in bed it is so bad, in susceptible in- 
dividuals, that sleep is well-nigh impossible. The itching 
gives rise to scratching, and the scratching to the secondary 
symptoms of the disease — scratched papules and eczematous 
patches. 

The first thing that the patient notices is that his skin 
itches. To relieve this he scratches, and sooner or later, 
according to the resistance of his skin, he produces pinhead- 
sized excoriations. Later, the irritation continuing, ecze- 
matous patches may result. When he presents himself to 
the physician, the latter will find on examination excoria- 
tions due to scratching, and he will notice that the lesions 
are located principally between the fingers, on the anterior 
surface of the wrists and somewhat on the forearms, about 
the axillae, upon the breasts about the nipples in women, 
upon the male genital organs, about the umbilicus and 
lower part of the abdomen, and often upon the buttocks 
of both sexes, and, in children especially, upon the anterior 
surface of the ankles and between the toes. In adults, 
these latter situations are not so frequently affected. Closer 
examination may be rewarded by the discovery of the 
pathognomonic sign of scabies, namely, the cunieulus, or 
burrow, which is usually found most readily on the inner 
border of the hand, on the inside of the fingers, and on 
the penis. It forms a delicate, slightly raised, whitish or 
grayish, wavy, often bowed line, from one-eighth to one- 
half an inch in length, and having a white speck at one 



568 DISEASES OF THE SKIN. 

end which marks the place where the itch-mite is. These 
are not always to be found ; indeed , in most cases they are 
difficult to find, because they are broken up either by the 
occupation of the individual, by the use of soap and water, 
or by scratching. In people with delicate skin the burrow- 
ing of the itch-mite will set up an inflammatory process, 
and papules, vesicles, and pustules will form, quite inde- 
pendently of the scratching. 

While the regions mentioned are the ones always affected 
in well-marked cases, variations in the extent of the dis- 
ease are observable. In some cases the hands are free, 
and but few lesions are present anywhere. Here, if it is 
a male, the crucial test will be the examination of the 
privates, where a scratch-mark or a burrow will be found 
almost without fail. In other cases hardly any part of the 
body will be free from excoriations, pustules, or eczematous 
patches, excepting the face, which is affected only excep- 
tionally, and then nearly always in children. In these bad 
cases furuncles and large ecthymatous pustules join them 
selves to the already multiform eruption of scabies. Urti- 
caria is also present in some cases, its wheals being inter- 
spersed among the other lesions. Should some intercurrent 
fever arise, the symptoms of scabies will subside, to reap- 
pear when the fever is past. The so-called Norwegian 
Itch is only a very much aggravated form of the disease, 
on account of the want of personal cleanliness of the peo- 
ple. The face in this form may be affected, the nails 
split and shed, and the palms and soles covered with 
thick crusts. 

Etiology. Scabies is due to the irritation set up by 
the acarus scabiei and by the scratching employed to re- 
lieve the same. The vesicles, papules, or pustules about 
the burrows are due directly to the acarus ; it may be on 
account of some irritating substance secreted by it. The 
disease is contagious, but requires prolonged contact, as 
by holding the hand or sleeping with an infected person. 
It is very rare for it to be communicated to a physician 
in examining a patient. 



SCABIES. 



569 



According to Greenough, 1 it is most prevalent between 
the ages of five and thirty, and comparatively rare after 
the fiftieth year. This, he thinks, is due to the fact that 
in advanced life the epidermis becomes harder and dryer, 
and forms a less suitable habitat for the acarus. A few 
years ago the disease was not common in this country, 

Fig. 78. 




Acarus scabiei. Back. 



but now it is an every-day occurrence to meet with new 
cases in our dispensaries, and not an infrequent one to 
meet with it in private practice. 

Pathology. The acarus scabiei is very small, being 
barely visible to the naked eye, the female being but one- 
sixtieth to one-eightieth of an inch long, and the male 
still smaller. Its width is about two-thirds of its length. 

1 Boston Med. and Surg. Journ., Sept. 23, 1886. 



570 DISEASES OF 1HE SKIN. 

It has eight legs — four on each side of its head, to which 
suckers are attached, and four posteriorly, to all of which, 
in the female, bristles are attached ; while in the male the 
inner ones are wanting in bristles, but provided with 
suckers for attaching himself to the female in copulation. 
On the back are a number of short bristles. A glance at 

Fig. 79. 




Acarus scabiei. Under surface. 

the accompanying plates will describe the animal better 
than words. 

The impregnated female acarus having landed on the 
skin, soon stirs about, and having found a suitable place, it 
rests on its hind feet, takes an oblique position, pierces the 
skin, and bores a hole, into which it forces itself. It lodges 
in the deeper layers of the epidermis, above, and sometimes 
in the mucous layer. It bores a burrow equidistant be- 
tween the surface of the epidermis and the level of the 



SCABIES. 



571 



papillae of the corium. Being prevented by the bristles on 
her back from moving backward, she moves forward, and 
lays her eggs. Her duration of life is from six weeks to 
two months, and during this time she lays some fifty eggs. 



Fig. 80. 




Burrow of scabies with acarus. (After Kaposi.) 

These hatch out, reach the surface of the skin, meet the 
male, become impregnated, bore in their turn into the 
skin, and so keep up the process. As the thinnest parts 
of the skin are most easily punctured, it is in these 



572 DISEASES OF THE SKIN. 

parts that we find the lesions most commonly. The 
scratching often extends far beyond the sites of the bur- 
rows Fournier found that an acarus died in seven days 
when immersed in cold water, in ten days when in warm 
water, and in two or four days in a solution of green soap. 
He denies the commonly accepted view that the acarus is 
a night-prowler, though he allows that it is most active 
at night. 

Diagnosis. The presence of pustules and scratch- 
marks between the fingers, on the anterior face of the 
wrists, about the umbilicus, on the breasts in women or the 
genitals in men, is enough to make the diagnosis of scabies. 
If a cuniculus can be found, it will be corroborative evi- 
dence. Eczema is more patchy and is not so markedly 
limited to the characteristic locations of scabies. Pedicu- 
losis vestimentorum presents long, parallel scratch-marks 
instead of the small excoriations of scabies, and their char- 
acteristic locations are over the shoulders, about the girdle, 
and along the outside of the arms and the inside of the 
thighs where the seams of the clothing come. The itch- 
ing of scabies is worst at night, while that of pediculosis 
is most marked in the daytime. Urticaria is a general 
disease characterized by wheals, and shows no tendency 
to localize itself in certain regions. Should urticaria com- 
plicate scabies, the wheals will be disseminated while the 
lesions of scabies will be most marked in their charac- 
teristic locations. 

Treatment. If the disease is recognized, there is no 
difficulty in curing it, though there are various methods 
employed. Perhaps the oldest and one of the most reli- 
able, though not the most rapid " cure," is to have the 
patient take a warm bath with soap and water, scrubbing 
himself thoroughly so as to remove as much of the old 
epidermis as possible. Then he should dry the skin with 
vigorous friction, and rub into every diseased spot ordi- 
nary sulphur ointment. When this is done he should smear 
the rest of the skin with the ointment, put on the same 
clothes, and go about his business. The rubbings with 



SCABIES. 573 

the ointment are to be repeated morning and night for 
three days, the patient wearing the same underclothing by 
day, and bed- and night-clothing by night. At the end 
of three days another bath is to be taken, the clothing 
changed, and the patient should then present himself for 
examination. If fresh lesions are found, a second course 
should be taken, which most always will be sufficient. 
An artificial eczema is apt to be set up by the sulphur, 
and as eczema itself itches we must not take the continu- 
ance of pruritus beyond the second course as evidence of 
the scabies not being cured. It is better to stop the sul- 
phur for a few days, and put the patient upon a mild, 
protective dressing to his skin, such as vaseline and corn- 
starch. If the itching grows worse instead of better, a 
third course of rubbing must be gone through with. In- 
stead of plain sulphur ointment we can add balsam of 
Peru, about J a drachm to the ounce, or use the modi- 
fied Wilkinson's ointment, as follows : 

U Sulph. subliniat.. 
01. cadini, 
Creta praeparat., 
Sapo viridis, 
Adipis, / "" M. 

S. Sherwell, 1 instead of using sulphur in ointment form, 
has the patient rub into the skin the dry sulphur powder 
and throw in between the sheets of the bed a f teaspoonful 
of the same. I have tried this plan in private practice 
with perfect success. The treatment in the St. Louis 
Hospital of Paris is a heroic one, but is said to cure in 
one hour and a half. According to Fournier, the pa- 
tient is scrubbed violently for half an hour with green 
soap ; then for another half hour the scrubbing is con- 
tinued while he is in a bath ; then he is rubbed with 
Helmerich's ointment : 



} 


aa £iv; 


aal6 




3iiss ; 


10 


} 


aa oJ 5 


aa 32 



R 



Potass, carbonat., 


^ss; 


15 


Sulphur, sublimat., 


li; 


30 


Adipis, 


3 x ; 


320 



M. 



i New York Med. Journ., 1S93, i, 432. 



574 DISEASES OF THE SKIN. 

Now he puts on his clothes without removing the salve, 
and is discharged cured. In private practice Fournier 
recommends the use of a good toilet soap for the prelim- 
inary rubbings, and then Bourguignon's ointmeut as fol- 
lows : 

R Glycerini, 200 parts. 

Gum. tragacanth., 5 " 

Sulph. sublimat., 100 " 

Potass, carb., 35 " 

01. lavandulae, "] 

01. menth. pip., "i aa 150 ' 

01. caryophylli, 
01. cinnamomi, J 



M. 



This is to be followed by a bath and powdering with corn- 
starch. It cannot be used for children, or in extensive 
cases in adults where there is much excoriation. It is 
vastly more agreeable than using an ointment. 

ft-naphtol in 5 to 10 per cent, strength in ointment 
or oil, is a good remedy, free from the sulphur smell, 
and not so irritating. Kaposi recommends it in the fol- 
lowing form : 

R /3-napb.tol., 15 parts. 

Sapo. viridis, 50 " 
Cretae alb. pulv., 10 •' 

Adipis, 100 " M. 

and Crocker says : " I can speak of it in the highest 
praise." It is well fitted for private practice. McCall 
Anderson extols styrax liquida with a double amount of 
lard. As the itch is very prevalent in Scotland, the doc- 
tor should know of what he speaks. Too free use of this 
remedy may cause a nephritis, so patients using it must 
be watched. Epicairhi, 10 per cent, in ointment, is a 
recent remedy well spoken of. I have found it quite as 
irritating as is sulphur. 

For infants and young children, balsam of Peru is the 
pleasantest application we can make, it being rubbed in 
morning and night, either pure or diluted with sweet 
oil ; or a mitigated form of sulphur ointment mav be 



SCLEREMA. 575 

used. It is possible to cause constitutional symptoms by 
using the balsam of Peru, but this is rare. 

In all cases the clothing and bedding must be disin- 
fected — washable things by boiling, and woolen clothing 
by baking or by ironing with a very hot iron. All 
affected members of the family must be treated at the 
same time. An irritable condition of the cutaneous 
nerves sometimes lasts long after the scabies is cured, 
and must not be mistaken for a still active itch. 

Prognosis. The prognosis is always good, provided 
the applications are made thoroughly enough. 

Scall or Scalled Head. See Favus. 

Scarlatina. Scarlet fever is an acute contagious erup- 
tive disease with an incubation period of one day to two 
or three weeks, with an average of eight days. It is 
characterized by a rapid rise of temperature at the begin- 
ning, which may reach 102° to 104° F., redness of the 
fauces, a strawberry tongue, and the appearance of a fine 
punctate scarlet rash, which, first appearing on the neck, 
chest, and flexures of the joints, rapidly spreads over the 
whole body. The redness may be even over all, so as to 
give a boiled-lobster appearance to the skin ; or the red 
points may be distinct, although close together. The 
redness usually disappears on pressure. Vesicles may 
appear. A great deal of constitutional disturbance and 
prostration usually attend the eruption, but convalescence 
is well established in the second week in uncomplicated 
cases. Abundant desquamation follows the subsidence of 
the eruption, which continues for days or weeks. 

Diagnosis. There is often a striking resemblance be- 
tween scarlatina and erythema scarlatiniformej and some 
other erythemata. (See Erythema.) 

Scherende Flechte. See Trichophytosis capitis. 

Schmeerfluss. See Seborrhcea. 

Schuppenflechte. See Psoriasis. 

Scissura Pilorum. See Atrophia pilorum propria. 

Sclerema. See Scleroderma. 



576 DISEASES OF THE SKIN. 

Sclerema Neonatorum. Synonyms : Scleroderma neo- 
natorum ; Induratio telae cellulose ; (Fr.) Algidity pro- 
gressive, L/endurcissenient athrepsique ; (Ger.) Das Scle- 
rem der Neugeboren. 

This happily rare disease was first differentiated from 
oedema neonatorum, according to Crocker, by Parrot, in 
1877. It may be primary, but most often it is secondary 
to some exhausting disease, such as pneumonia or intesti- 
nal catarrh. It may be present at birth, and rarely oc- 
curs after the first ten days of life. It is characterized 
by hardness of the skin, which generally at first is cir- 
cumscribed and affects the legs. It may be diffused from 
the first, or it soon becomes so, and extends to the lumbar 
regions, back, chest, and so all over the body, becoming 
universal by the fourth day. It may begin on the face, 
and it may stop before becoming universal. It may be 
but slightly developed on the chest. At first the skin is 
pale and waxy ; later, it becomes livid and cold, and the 
child looks as if frozen. The skin becomes attached to 
the underlying parts, smooth, tense, and does not pit on 
pressure. Movement is impossible for the child, and the 
body may be raised without bending a joint. When the 
face is affected it is impossible for the child to nurse. Its 
respirations are greatly reduced in number, its pulse falls 
to sixty per minute, its temperature is below normal, its 
breath is cool, and it dies within a week. The primary 
congenital cases are either stillborn or die in one or two 
days. Localized cases sometimes recover, the hardness 
of the skin disappearing. 

Etiology. The cause of the disease is obscure. It is 
seen almost exclusively in foundling asylums and among 
the very poor. It is, therefore, a disease of depressed 
vitality. Langer x regards it as the result of solidification 
of the fat, which in infants contains 31 per cent, of palmi- 
tin and stearin, that of adults containing 10 per cent. 
The fat in infants, he says, is nearly all concentrated in 
the subcutaneous tissues, where it is five times as thick 
1 Wien, med. Presse, 1881, xxii., 1375. 



SCLER DERMA. 577 

relatively as it is in adults. Naturally, an infant's tem- 
perature is higher than an adult's. If it is lowered by 
any depressing cause, the fat may solidify. Solidifica- 
tion may take place also under the action of cold, or by 
oxidation, as in fevers, withdrawing some of the constit- 
uents of the fat. Parrot regards the disease as one of 
desiccation from the drain of a diarrhoea, or the like. 

Diagnosis. Sclerema neonatorum is differentiated 
from oedema neonatorum by being more general in its dis- 
tribution, by the skin being harder and more tense, and 
not pitting on pressure, and by the rigidity of the joints. 
Scleroderma occurs at a later age than does sclerema, and 
the skin lacks the coldness of the latter. There are no 
other diseases with which sclerema can be confounded. 

Treatment. The course of the disease is almost in- 
evitably toward a fatal termination, and little more can 
be done than to keep the little body as warm as possible, 
to rub in oil, and to administer concentrated nourishment 
and stimulants. Money x reported a case in 1889 that 
was cured in six weeks by mercurial inunctions. There 
was no history of syphilis in the case. 

Scleriasis. See Scleroderma. 
Sclerodactylie. See Scleroderma. 

Scleroderma. Synonyms : Sclerema seu Scleroma adul- 
torum ; Scleriasis ; Dermato-sclerosis ; Chorionitis ; Scler- 
ostenosis ; (Fr.) Sclereme des adultes, Sclerodermic ; 
(Ger.) Hautsclereme ; Hide-bound disease. 

A subacute or chronic disease, characterized by hard- 
ness and rigidity of the skin. 

Symptoms. The name of this disease indicates the 
most peculiar feature of it — that is, hardness of the skin. 
It may come on without apparent cause, the patient first 
noticing the stiffness of the skin ; or it may follow expos- 
ure to dampness and cold, and be preceded by pains of 
rheumatic nature. It may begin in any part of the skin, 
but has a preference for the upper half of the body. It 

i Lancet, 1889, i., 526, 
37 



578 DISEASES OF THE SKIN. 

is usually symmetrical, though it may be more pronounced 
on one side than on the other. Having begun, it spreads, 
it may be very slowly, or it may be so rapidly as soon to 
involve large areas of the body. It often runs a capricious 
course, growing better and worse, and leaving sound areas 
in the midst of the diseased parts. There may be one 
patch or a number of patches, and the patches assume 
many shapes, though most commonly they are elongated, 
running lengthwise of the limb. 

There are two varieties of the disease : 1. The infiltrat- 
ing form. In this there is a good deal of infiltration of 
the skin, which is hard, cannot be pinched up, does not 
pit on pressure, and is attached to the deeper structures. 
The appearance given to the affected part is cadaveric. 
In some cases there may be hard cedema. The affected 
partis usually on the level of the surrounding parts, though 
it may be slightly raised. The infiltration merges grad- 
ually into the neighboring parts, its border being ill de- 
fined and more readily felt than seen. The natural folds 
of the skin are obliterated, erythema may be present at 
first, and telangiectases are frequently observed upon the 
surface. Not infrequently the patch has a lilac border. 
The color of the skin is paler than that of the normal in- 
tegument, and in some places it may be that of ivory. 
Some scaling may be present, or pigmentation of a mot- 
tled or diffused character may give the patch a fawn or 
black color. Owing to the stiffness of the skin the move- 
ment of the joints is interfered with, a state of pseudo- 
ankylosis being established. If the face is affected, it 
loses its expression, and the features become immobile. 
The eyelids may escape for some time ; but if the disease 
passes on to the atrophic stage, soon to be mentioned, the 
eyes become wide open and cannot be closed. If the 
chest is much affected, respiration is interfered with. The 
temperature of the skin is usually lowered one or two 
degrees. It may be normal or somewhat elevated. Sen- 
sibility may be increased, normal, or decreased. Pruritus 
is at times annoying. The secretions of the skin are 



SCLERODERMA. 579 

lessened with the increase of the disease. The disease 
may invade all the mucous membranes. 

2. The atrophic form may succeed the infiltrating form 
after months or years. Crocker thinks that it is prob- 
able that atrophy follows the oedematous infiltration only. 
When atrophy begins it is progressive, and the skin be- 
comes dry, wrinkled, parchment-like. It is most often 
the upper part of the body that is affected — the face and 
arms. Continuous contraction of the skin produces an 
atrophy of the muscles under it, so that finally nothing 
remains of the original structures but the skin and bones, 
and the joints are ankylosed. The face being affected, 
we will find a corpse-like expression, wide-open eyes with 
ulcerated corneas, shrunken gums with loosened and fall- 
ing teeth. The limbs being affected, slight injuries will 
produce ulcerations over bony prominences, and the limbs 
will be semiflexed. The sclerodactylie of Ball is sclero- 
derma of the atrophic variety, affecting the hand and 
causing marked atrophy, loosening the joints, and dis- 
torting the hands, u so that the third and fourth fingers 
are curled up into the hand, the first and second are bent 
at the first phalangeal joint, while the thumb phalanges 
are over-distended." (Crocker.) 

The general health remains unaffected in both forms, 
often for years ; but should the disease be very pro- 
nounced, at last a marasmic condition develops and death 
occurs. Apart from the pruritus and feeling of stiffness, 
we may have no subjective sensation, excepting that pain 
on pressure is exquisite. At times burning is complained 
of. The disease, when of the infiltrated variety, tends 
to a slow and interrupted course toward recovery. In the 
atrophic variety recovery may take place. Of course, 
the atrophied skin will never regain its natural texture, 
but the disease may cease to spread and increase. At 
best its subject is but a sorry specimen. 

Children may have scleroderma, the youngest reported 
case being thirteen months. In them the disease is said 
to run a more rapid course, both in development and re- 



580 DISEASES OF THE SKIN. 

covery, than it does in the adult. Vidal x describes a 
form of scleroderma following a lesion of the skin, such 
as an eczema, which gives rise to a lymphangitis, and is 
usually met with on the leg. 

Morphcea, Keloid of Addison, is the circumscribed form 
of scleroderma. It occurs either as circumscribed, vari- 
ously sized, oval or irregularly shaped patches, or in the 
form of bands, the former being the more common. It 
begins as a congested, red, rosy, or lilac macule, which 
enlarges, pales in the centre, becomes hardened, and as- 
sumes the form of a characteristic patch of the disease. 
This patch looks like a piece of old ivory or of lard set 
in the skin, being of a yellowish-white color. The color 
may be pinkish, yellow, brown, or even black. The 
skin over the patch is usually smooth and easily pinched 
up. It may be wrinkled, or eroded in the centre. It 
may be level with the surface of the skin, or raised above 
it, or sunken below it. Around it is a lilac border due 
to dilated vessels. When the patch is pinched between 
the fingers it feels firm, like leather. There may be but 
a single patch or a number of patches. As a rule the 
disease is unilateral. After a varying length of time it 
may disappear spontaneously, although it may remain for 
a number of years. There are usually no subjective 
symptoms, and the disease remains unchanged until it 
disappears. In some cases it enlarges by new patches 
developing at the periphery of the old one and uniting 
with it. Exceptionally there may be some itching or 
pain, and ulceration may occur. Sensation is generally 
preserved. The band form is usually single, and may 
form a depressed sulcus or a raised ridge, looking much 
like a cicatrix. In addition to the bands there may be 
atrophic spots. 

The most common locations of morphoea are anywhere 

on the trunk, but specially on the breasts ; on the head 

and face in the parts supplied by the fifth nerve ; and on 

the limbs. It is not infrequently associated with other 

i Gaz. des. Hop., 1878, 11, 939. 



SCLERODERMA. 581 

nervous phenomena, and may occur along the course of 
a nerve, like zoster. Nettleship x has reported a case in 
the region of the first and second divisions of the fifth 
nerve with paralysis of the intraocular branches of the 
third nerve, which in time had associated with it hemia- 
trophy of the whole of the left side of the head. There 
is no disturbance of the general health. The secretion 
of sweat over the patches may be normal, lessened, or 
absent. When the disease disappears it may leave no 
trace of itself; or it may be followed by pigmentation, 
or even permanent atrophy, not only of the skin, but 
also of the muscles. A form of leprosy has been 
wrongly named morphoea. 

Etiology. Women are far more often the victims of 
scleroderma than are men — three to one. It is most 
common in young and middle-aged adults. Apart from 
this, we are in uncertainty as to the true cause, though 
rheumatism, gout, exposure to cold and heat, bad hygiene 
and poor food, and neurotic influences have each been 
found in apparent causative relation to the disease. At 
the foundation of the trouble there is supposed to be 
some defect in the nervous system, not improbably in the 
vasomotor centres. " Most of the symptoms are refer- 
able to obstruction, on the one hand, to the arterial blood 
supply, and on the other, to the venous and lymph flow." 
(Crocker). 

Pathology. There is atrophy of the fat in the 
derma and subcutaneous tissue, with condensation and 
increase of the connective tissue. The bloodvessel walls 
are thickened, and their lumina narrowed by the pressure 
of surrounding masses of cells of unknown origin. These 
cells are plentiful also in the neighborhood of the glands, 
which, in the later stages, may be atrophied. The pa- 
pillae are hypertrophied only in those cases which show a 
papillomatous tendency. 

Diagnosis. There is no other disease of the skin 
with which diffused scleroderma could well be confounded, 
i Trans. Clin. Soc. Lond., 1882-3, xvi., 199. 



582 DISEASES OF THE SKIN. 

excepting sclerema or oedema neonatorum, or cancer en 
cuirasse. The age at which the first two occur — namely, 
the first few days of life — would throw them out. Can- 
cer en cuirasse is more rapidly fatal in its course, is at 
first or soon marked by subcutaneous nodules that tend 
to break down and ulcerate, and is accompanied by lanci- 
nating pain. 

Keloid differs from morphcea in having claw-like pro- 
cesses, in being more vascular and harder, and in want- 
ing the old-ivory color and lilac border. Leprosy has 
anaesthetic patches, which morphcea has not. Vitiligo is 
a pigment change only, and has no other symptoms. 

Treatment. It is doubtful if treatment is ever di- 
rectly of avail. At best it is unsatisfactory. A general 
symptomatic treatment with tonics, good diet, aud main- 
tenance of the body heat is indicated. Stelwagon recom- 
mends the administration of arsenic, sodium salicylate, 
and cod liver oil. Thyroid extract should be tried. 
Galvanism, inunctions of the skin with oil, and massage 
may be tried. West 1 has reported amelioration in one 
case by the external use of chaulmoogra and olive oils. 
Stelwagon has had good results in morphcea from oil of 
turpentine 1 to 2 parts in 6 of oil of sweet almonds, or 
with 1 part of beta-naphtol, 2 parts oil of sweet al- 
monds, and 10 parts of lanolin. Hyde has obtained 
benefit by the use of common salt, either moistening it 
with warm water until it is partially dissolved, and then 
rubbing it briskly over the entire surface of the body 
excepting the face, and then washing it off with water of 
decreasing temperature until cold water is used ; or a 
warm tub or sponge bath is taken containing J of a pound 
of salt to the gallon. Mercurial or thiosinamin plaster 
may be tried. I have seen one case improved by inunc- 
tions of vaseline containing 10 per cent, of salicylic acid. 
Electrolysis has proved helpful in small patches of mor- 
phcea. The high frequency current is sometimes useful. 

Prognosis. While recovery may take place, it is 

1 Trans. Path. Soc. Lond., 1883, xvi., 252. 



SCROFULODERMA, 583 

uncertain as to its occurrence. Death may result in the 
diffused form. In children the prognosis is more favor- 
ble. 

Scleroderma Neonatorum. See Sclerema neonatorum. 
Scleroma Adultorum. See Scleroderma. 
Sclerostenosis. See Scleroderma. 
Scrofulide Boutoneuse Benigne. See Prurigo. 
Scrofulide Crustacee Ulcereuse. See Tuberculosis cutis. 
Scrofulide Erythemateuse. See Lupus erythematosus. 
Scrofulide Tuberculeuse. See Lupus vulgaris. 

Scrofuloderma. Modern pathology has led, or is leading, 
us to use the term tubercular as synonymous with scrofula, 
and a number of dermatoses that were for many years 
regarded as scrofulodermata have been proven to be due 
to the bacillus tuberculosis. The most brilliant example 
of this is lupus vulgaris. Many of the scrofulides of the 
French have been shown by more careful observation to 
belong to various other well-recognized forms of skin 
disease. The marks of a scrofulous affection are, accord- 
ing to Bazin: (1) the involvement of the deeper layers of 
the skin ; (2) the sharply circumscribed character of the 
lesions ; (3) the absence of pain ; (4) hypertrophy followed 
by atrophy of the affected parts ; (5) the reddish, violaceous, 
or livid color of the lesions ; and (6) indelible cicatrices 
left by the same. 

In the present condition of our knowledge of the sub- 
ject, and in a book of this sort, it is impossible to do more 
than to place here a few affections of the skin that do not 
fit in under other well-established diseases, while premis- 
ing our remarks by saying that they are either really in- 
stances of cutaneous tuberculosis or due to its toxins, or 
will eventually be taken out of their present position as 
scrofulodermata. In all of them we have, at the same 
time, that general make-up of the individual that long has 
been recognized as scrofulous. The patients are mostly 
young subjects, flabby of flesh, with pasty or doughy com- 
plexions or transparent skins, thick upper lips, perhaps 



584 DISEASES OF THE SKIN. 

with clubbed fingers, a marked tendency to chronic catar- 
rhal inflammations of all the mucous membranes, chains 
of enlarged glands in the neck, and perhaps with some 
old or present bone lesions. They are usually dull and 
apathetic, but may be unusually intellectual, and are prone 
to die with tubercular lung diseases. 

The most common scrofuloderm is that resulting from 
a suppurating caseous gland, usually of the neck — the 
scrofulous ulcer. The gland, before it breaks down, im- 
plicates the skin over it, and it becomes of violaceous or 
livid color, attached to the underlying parts. By and by 
the skin gives way at one or several points ; the sanious, 
unhealthy pus escapes through the openings ; these en- 
large, coalesce with others, and so form the characteristic 
ulcer. This has undermined edges ; is of irregular shape ; 
its base is covered with flabby granulations ; it discharges 
a thin, sanious pus ; shows little tendency to crusting ; is 
almost painless, and heals very slowly, leaving a puckered, 
disfiguring scar that is often bridled, with bands of con- 
nective tissue running across the site of the ulcer, under 
which a wooden tooth-pick, or the like, can be passed. 
Only one gland may be affected, or there may be a num- 
ber of them that enlarge and break down. This same 
form of ulcer may originate from what is called a scrofu- 
lous gumma, a subcutaneous tubercle independent of the 
glands, that slowly enlarges to a soft tumor, breaks down, 
and ulcerates. These tumors frequently occur on the 
limbs, and the bones may be involved in the destructive 
processes set up. 

While this is the most common scrofuloderm, we occa- 
sionally meet with two forms described by Duhring — the 
large and the small pustular scrofuloderm. The former has 
"large, rounded, ovalish, or irregularly shaped, yellow- 
ish, flat pustules, with a deep-red or violaceous areola." 
This begins to crust in the centre, and the crust is usually 
flat and scanty, brownish and adherent. Underneath it is 
an ulcer with the characters and course of those just de- 
scribed. There may be one, two, or more lesions. The 



SCROFULODERMA. 585 

small pustular scrofuloderma "consists in the formation 
of pinhead- and small split -pea-sized, disseminated, yel- 
lowish, flat pustules, with usually a raised, violaceous 
areola." These crust over with depressed yellowish or 
gray adherent crusts, which when removed, or when 
they fall off, leave depressed, punched-out scars resem- 
bling variola. Their course is very chronic and painless. 
They occur upon the face and extremities of strumous 
individuals. This form is probably the same as that now 
called acne necrotica. 

Etiology. The causes of these scrofulodermata are 
those of the strumous state plus infection by the tubercle 
bacillus, and need not be gone into here. They are most 
commonly met with in early life. 

Diagnosis. The scrofulous ulcer differs from that of 
lupus vulgaris in an entire absence of the characteristic 
lupous tubercles, and in its history of beginning in a 
caseous gland. Moreover, in lupus we do not have, as a 
rule, the pronounced strumous condition that we have in 
the scrofuloderm. The pustular scrofuloderms sometimes 
resemble syphilis, but there is an absence of other signs of 
syphilis, and the presence of the strumous state. More- 
over, the pustular syphilide is generally far more dissem- 
inated than is the scrofuloderm; its course is far more 
acute; it yields more readily to treatment, and leaves a 
smoother, less disfiguring scar. 

Treatment. The treatment of the ulcers, as well as 
the softening glands, is upon surgical principles. The 
regulation of the diet and hygiene of the patient, and the 
administration of cod-liver oil, iron, the compound syrup 
of the hypophosphites, or other tonic, is the most essential 
part of the medicinal treatment. Locally, to the pustular 
scrofuloderms we may apply iodoform ointment, aristol, or 
other antiseptic powder, or mercurial ointments or lotions. 
Crocker speaks well of chaulmoogra oil emulsion in the 
dose of 10 to 30 minims, combined with its external use 
as an ointment in the strength of 1 part to 3. 



586 DISEASES OF THE SKIN. 

Scrofuloderma Verrucosum. See Tuberculosis verrucosa 
cutis. 

Scurvy. See Purpura. 
Seborrhagia. See Seborrhoea. 

Seborrhcea. Synonyms : Stearrhoea, Steatorrhcea, Sebor- 
rhagia, Fluxus sebaceus, Acne sebacea, Pityriasis, Ichthy- 
osis sebacea, Tinea amiantacea seu asbestina, Dermatitis 
seborrhoica, Eczema seborrhoicuin, Lichen circinatus ; 
(Fr.) Acne s6bacee. Acne" fluente ; (Ger.) Schmeerfluss, 
Gneis ; (Ital.) Seborrea. 

A functional disorder of the sebaceous glands, in which 
there is a hypersecretion of sebaceous matter, which may 
be of too fluid or too solid consistence, and forms either 
an oily coating or greasy crusts on the skin. 

Symptoms. Normally the sebaceous glands secrete 
only sufficient oil to keep the skin soft and supple. This 
normal oil is not visible to the naked eye. Under certain 
imperfectly understood conditions the glands secrete a too 
fluid and abundant oil that is readily seen as an oleagi- 
nous coating of the skin. This form of seborrhoea is called 
seborrhcea oleosa, and by many authorities is now declared 
to be the only form of seborrhoea. By others, and per- 
haps the majority, it is thought that under certain other 
equally inperfectly understood conditions the secretion of 
these glands is not only too abundant, but also too con- 
sistent. Then the sebaceous matter cakes upon the skin 
in the form of more or less thick plates or masses, and to 
this condition the name of seborrhoea sicca is given. The 
latter form is regarded by those who believe that there is 
but one form of seborrhoea as seborrhoeal dermatitis or 
eczema. In deference to the older teachings, boths forms 
will be described. 

The most common locations of seborrhoea are, naturally, 
those regions where the sebaceous glands are the largest 
or most numerous, namely, the scalp, the chest, the in- 
terscapular region, and the face. 

Seborrhcea oleosa, while it may occupy any or all of 



SjEBORRHCEA. 587 

these regions, is usually subjected to us for treatment only 
when it occurs upon the face. Here it is seen most often 
on the nose, where it forms a greasy coating. At times 
this is so slight as to be felt rather than seen, imparting a 
slippery sensation to the finger. At other times it is so 
abundant that it can be seen at a distance as drops or 
beads of oil, and when it is removed with a cloth or blot- 
ting-paper it leaves an oily stain upon it. When it is 
wiped off it at once reforms. As the greasy patch catches 
the dust, the face is apt to look dirty. At times the skin 
of the nose may be hypersemic. The forehead is, like- 
wise, a not uncommon site for this form of seborrhoea. It 
may occur on the scalp, and render the hair unusually 
oily. It is most often noticed when the patient is bald. 
It is apt to cause alopecia. Upon the nose it may occur 
as the only disease of the skin. Upon the forehead and 
nose it is not an unusual accompaniment of acne. Acne 
and comedones may complicate the disease in any location. 

Seborrhoea sicca occurs with much greater frequency 
than does the oily form of the disease. We are called 
upon to remove it from all the regions already mentioned 
as the locations for the manifestations of seborrhoea. It 
most usually appears in the form of yellowish or grayish 
fatty plates or masses, which when taken and rubbed be- 
tween the fingers impart a greasy feel. Upon the scalp 
it constitutes one form of dandruff. Here it may be gen- 
eral, involving the whole scalp ; or it may locate itself in 
certain places in a more pronounced way than in others ; 
or it may take the form of rings. It not infrequently oc- 
curs as a band on the forehead following the edge of the 
hair. The hair is dry, and after a time, the seborrhoea 
continuing, it begins to fall, and at last baldness is estab- 
lished. 

In this form of seborrhoea the hairy regions are espe- 
cially affected, and we find it in the eyebrows, bearded 
portions of the face, and the hairy portions of the chest. 
The axilla? and pubes are rarely affected. In all these 
places it presents similar appearances — yellowish or gray- 



588 DISEASES OF THE SKIN. 

ish fatty plates. Upon the chest it is not uncommon to 
see the fatty matter in little heaps, piled up, as it were, 
about the mouths of the hair follicles. Close observation 
will show that the follicle mouths are wider open than 
they should be. As in the oily form, the skin feels 
greasy, and acne and comedones may be present. The 
interscapular region is frequently affected, and both here 
and on the chest the disease often takes the form of round 
or irregularly shaped patches which look as if they were 
covered with a brownish-yellow varnish. This is the 
seborrhcea corporis of Duhring and the lichen circinatus of 
the older English authors. 

Aside from the appearance of the fatty crusts and a 
slight amount of itching when the patient is warm, this 
form gives rise to no symptoms. When the crusts are 
removed the underlying skin is of normal appearance. It 
may be slightly paler than it should be, but it is never 
moist. What the patient complains most about is that 
flakes from the crusts, becoming loosened, fall upon the 
clothing and make it look as if powdered. If the patient 
happens to be bald, he does not find the yellowish fatty 
crusts upon his bald head desirable. But the most seri- 
ous aspect of the case is that if the disease is not cured it 
is very sure to cause the hair to fall, especially if the 
patient is at all predisposed to baldness. 

There is a second variety of seborrhoea sicca, in which 
a varying amount of dermatitis is added to the seborrhoea. 
Then there will be a rim of redness about the fatty crust, 
and when the crust is removed from the skin the under- 
lying part will be seen to be red. In this variety there 
will be far more decided itching and burning than in the 
preceding variety. It is to be noted that although the 
skin is red, it is always dry and never infiltrated, in these 
respects differing from eczema. 

Upon the nose this variety of seborrheal dermatitis 
forms a yellow plate with a red line about it. At times 
this plate may be extensive enough to cover the whole 
nose. More frequently the disease is limited to the fur- 



SEBORRHEA. 589 

rows behind the alee nasi, and then assumes the form of 
fatty plates upon a good deal of underlying redness. The 
eyebrows and bearded portions of the face are also quite 
commonly affected, but rather as a diffuse redness com- 
bined with a branny scaling than as a solid plate sur- 
rounded by a red line. 

Besides the regions already mentioned as the usual loca- 
tions of seborrhoea, we meet with the disease also upon the 
ears (in the tragus and behind the ears) and in the anal 
fold. The scalp is, however, by far the most frequent 
location of the disease, and here it may exist alone for 
years. Whenever it exists elsewhere it is sure to be found 
at the same time upon the head. 

In infants the disease is very common, taking the form 
of thick crusts upon the scalp that are often of a dirty- 
gray color. These give the careful mother a good deal of 
annoyance, she being in great dread lest some one should 
think that she is not careful to keep the precious baby 
clean. This form of the disease is usually the remains 
of the vernix caseosa. 

Etiology. The usual etiological factors of seborrhoea, 
as given in the text-books, are debility, chlorosis, consti- 
pation, and a number of other things, indicating that the 
condition of the patient is below par. Of course, the ability 
of these to cause seborrhoea is questioned ; but that they 
are quite capable of aggravating the disease, I have no 
doubt. It is quite common to see seborrhoea appear on the 
scalp after some constitutional illness. The disease affects 
all classes and conditions of men, all ages, but with the 
greatest frequency between the ages of fifteen and thirty, 
and both sexes. 

There are many things that seem to indicate a conta- 
gious element in the etiology of the disease. Cases have 
been reported in which a husband or wife has contracted 
dandruff after marriage, he or she having been, before, free 
from the same. The experiments of Lassar and Bishop 
point in the same direction. They took the scales from 
the head of a student who was losing his hair, and, having 



590 DISEASES OF THE SKIN 

made a pomade of them with vaseline, rubbed the same 
into the back of a guinea-pig, and the pig became bald. 
Up to two years ago we accepted without question the 
theory that seborrhoea is a functional disease of the seba- 
ceous glands. This is now doubted by some authorities. 
Unna teaches that the process is inflammatory from the 
start, and that the oil that fills the epithelial scales comes 
not from the sebaceous glands, but from the sweat glands. 
What we have called seborrhoea sicca he would have us 
call, for the present at least, seborrheal eczema. (See 
Dermatitis seborrhoica.) He regards it also as parasitic. 
In support of his thesis he presents us with microscop- 
ical studies and certain arguments. His work has been 
reviewed by other competent pathologists, and his obser- 
vations have been substantiated by their findings. His 
proposition that the sebaceous glands are not responsible 
for seborrhoea has not been accepted generally. What is 
called seborrhoea oleosa, Unna believes to be nothing more 
than hyperidrosis, to which he gives the name of hyper- 
idrosis oleosa. This view he must take of necessity, on 
account of his theory of the office of the sweat glands. 

It is affirmed that seborrhoea is due to a microorganism. 
Brooke, of Manchester, believes that, to the parasite of 
seborrhoea without dermatitis, another parasite adds itself, 
to produce the dermatitis and the ring formation. For 
further information the reader is referred to the article on 
dermatitis seborrhoica. 

Diagnosis. The diagnosis of seborrhoea sicca is usu- 
ally easy. It is to be recognized by the presence of fatty 
grayish or yellowish plates or crusts, seated either upon a 
normal or slightly reddened skin. These crusts or plates 
differ from those met with in eczema in being more readily 
removed, and in imparting to the finger a greasy feel. 
Moreover, the crusts of eczema are of a more solid con- 
sistence, being formed by the drying of an almost muci- 
laginous discharge upon the skin. When eczema occurs 
upon the head the exudation glues the hairs together. In 
seborrhoea the hairs are not glued together, but are dry 



SEBORRHCEA. 591 

and powdery. In eczema there is more or less itching at 
all times, while in seborrhcea the itching comes on most 
generally when the head is hot, as from artificial lights, 
sweating and the like. In eczema there is moisture or a 
strong tendency thereto. In seborrhcea moisture is never 
seen. 

Psoriasis is another disease with which seborrhcea sicca 
is apt to be confounded, as it, too, occurs in the form of 
powdery scales and crusts upon the scalp. If a case pre- 
sents itself with these conditions upon the head alone, we 
may be very sure that we have to do with a case of seb- 
orrhcea, as psoriasis rarely exists upon that region alone. 
Seborrhcea usually occurs diffusely, while psoriasis occurs 
in the form of circumscribed patches. The crusts of seb- 
orrhcea are yellowish or grayish, while those of psoriasis 
are of a silvery hue. In some cases, however, seborrhcea 
will occur in circumscribed patches, and the crusts of 
psoriasis may be of a grayish hue. 

When seborrhcea sicca occurs upon the chest and back 
in the form of rings with scaly centers, we have before us 
a more difficult problem in diagnosis. Now we must de- 
cide whether we have to do with a seborrhcea, a ringworm, 
or a pityriasis rosea. The resemblance to ringworm is 
often very striking, but ringworm does not, as a rule, occur 
in so diffuse a manner. If, at the same time with the 
lesion on the chest, we find other lesions on the back 
between the shoulder-blades, we may be quite sure that the 
case is one of seborrhcea. Happily in any doubtful 
case of ringworm, we will surely find the trichophyton. 
Upon examining the scalp, if the disease be seborrhcea, 
we will surely find plain evidence of it there. There 
should be no clifflcutly in recognizing the preseuce of a 
ringworm on the scalp. In the differential diagnosis from 
pityriasis rosea we are deprived of the kindly aid of the 
microscope. Here, too, the occurrence of seborrhcea on 
the scalp will aid us in our decision. Moreover, pityriasis 
rosea is generally more diffused over the trunk than is 
seborrhcea, and occurs also on the arms and abdomen, 



592 DISEASES OF THE SKIN. 

By close inspection we may trace the development of the 
disease from its beginning as a small red spot through its 
successive growth into the typical oval to annular patch 
with its withered parchment or chamois-leather-like look- 
ing centre. It is scaly, never crusted. In some cases, 
however, the diagnosis will remain somewhat doubtful. 

Treatment. The treatment of seborrhoea is simple. 
It is somewhat in favor of the parasitic theory of the 
origin of the disease that the drugs that are most effica- 
cious in its cure are active antiparasitics. In my hands 
by far the most satisfactory remedy has been sulphur. 
After the removal of the crusts by washing with soap 
and water, the sulphur is to be applied in the strength 
of a drachm of the precipitated sulphur to an ounce of 
rose ointment. It should be well rubbed into the scalp, 
and the application repeated every night for one week. 
It must be remembered that the remedy is to be applied 
to the scalp and not to the hair, and that it is necessary 
to use only a very little of the ointment. After one 
week's use of the sulphur the head is to be washed 
with soap and water, and the salve, immediately reap- 
plied. During the second week it will be sufficient to 
make the application every other night. Thus the treat- 
ment is to be continued, the number of applications being 
reduced until they are made but once a week. By this 
time the disease will usually be cured. The patient is to 
be cautioned that relapses are likely to occur, and there- 
fore it will be best for him to keep a supply of his 
salve on hand, so as to attack the trouble as soon as 
it shows itself. After the first two weeks of the above 
detailed treatment, it is well to have the patient use a 
lotion of 20 per cent, sulphurous acid in dilute alcohol 
on the days when the pomade is not used. This over- 
comes the too oily effect of the pomade, while the pomade 
prevents the too drying effect of the alcohol. 

The ointment recommended by my distinguished friend, 
Dr. Bronson, is a very elegant as well as efficient substi- 
tute for the sulphur. It is — 



SEBOBBHCEA. 593 



M. 



R. Hydrarg. ammon., BJ-iJ 5 S -10 

Hydrarg. chlor. mitis, 9ij-iv ; 10-20 

Vaselini, ad gj ; ad 100 

This is to be used in the same manner as the sulphur 

ointment. 

While one or the other of these will bring the case to 

a happy issue, it is well to have a variety of means at 

command. H. R. Crocker * commends : 

& Ac. acetici, ^ss-j ; 15-30 

Resorcin. , 3J ; 4 

Aq. cologniensis, ^ij ; 60 

Glycerini, 3j ; 4 

Aquae rosae, ad ^viij ; ad 240 M. 

Some other remedies are salicylic acid in castor oil, 
3 per cent, strength ; resorcin in oil, diluted alcohol, or 
vaseline in 3 to 10 per cent, strength ; or a solution of 
hydrate of chloral, a drachm to the ounce. A favorite 
formula is : 

R Hydrarg. bichlor., gr. ij ; rl 

Resorcin., 3j > 4 

01. ricini, gtt. xv ; 1 

Alcohol, ad ^iv; ad 120 M. 

This will cause an exfoliation of the scalp in some cases. Re- 
sorcin should never be prescribed for those whose hair is 
white, gray, or blond as it stains the hair a greenish shade. 

For a soap, both for cleansing and stimulation, the 
tincture of green soap or the liquid Kreuznach soap may 
be used. If the scalp is peculiarly irritable, then it is 
best to use a milder soap, such as glycerin soap. 

The treatment of seborrhcea of the body and face is 
upon the same lines as that of the scalp, only on the 
body we can use an ointment instead of an oil. 

For the seborrhoea of infants usually all that is re- 
quired is to keep the scalp well oiled with olive oil. If 
this does not cure, then a mild sulphur ointment with 
vaseline may be used. 

For seborrhoea oleosa dabbing ether on the part will 

1 Clin. Journ., Lond., 1897, x., p. 81, 



594 DISEASES OF THE SKIN. 

most promptly remove the greasy look. Washing with 
soap and water will act as a stimulant. Powdering with 
sulphur and starch, or using a 3 per cent, solution of 
resorcin in alcohol and water, will tend to cure. 

In all forms general treatment will be called for if the 
patient is out of tone. General tonic treatment is re- 
quired in nearly all cases of seborrhoea oleosa. 

Under Alopecia furfuracea will be found further di- 
rections as to the treatment of seborrhoea of the scalp 
when it has led to baldness. See also Dermatitis se- 
borrheica, which is that which I have here described 
as seborrhoea sicca, in deference to the older teachings. 

Prognosis. Seborrhoea oleosa is often recovered from 
when the patient is in good general condition. Sebor- 
rhoea sicca is usually readily relieved, but is very sure to 
return, so that the patient must keep by him for further 
use any remedy he has found efficacious. 

Seborrhoea Congestiva. See Lupus erythematosus. 
Seborrhoea Nigricans. See Chromidrosis. 
Shingles. See Zoster. 

Siderosis. A defacement of the skin due to the en- 
trance into it of small particles of iron or steel, producing 
blue black marks. It is seen in ironworkers. 

Sommersprosse. See Lentigo. 

Spargosis. See Elephantiasis. 

Spedalskhed. See Lepra. 

Sphaceloderma. See Dermatitis gangrsenosa. 

Spider Cancer. See Telangiectasis. 

Spiradenoma. See Adenoma of sweat glands. 

Sporotrichosis Hypodermica. According to De Beuer- 
mann and Gougerot 1 this disease is due to the invasion 
of the skin by several kinds of Sporotrichium, a vege- 
table fungus. 

Symptoms. The invasion takes place insidiously. 
Once the disease begins it is progressive. It occurs in 
three forms. 

1 Annal. derm, et syph., 1906, vii.. 837. 



SPOROTRICHOSIS HYPODERMICA. 595 

1st Form. Three or four weeks after invasion there 
is an eruption of subcutaneous nodules over the whole 
body. Each nodule attains its full maturity and be- 
comes an abscess in from four to six weeks. They 
begin as small, subcutaneous, hard, elastic, movable, 
painless nodules, 5 to 6 mm. in diameter, which are 
but slightly elevated. The skin at this stage is un- 
changed. They slowly enlarge to the diameter of 20 
or 30 mm., become more elevated, and the skin over 
them becomes rosy, violaceous, or brown in color. In 
about four weeks' time softening of the nodes occurs. 
The nodes go on to form abscesses which do not tend to 
open of themselves. The contents of these abscesses is 
viscous or gummous, at first translucent though streaked 
with pus. Later it is purulent, opaque, and thick, and 
cultures show sporotrichium Beuermann. If an abscess 
is opened, the incision remains open, and a little thick 
serum wells out which may or may not be purulent. 
The incision gapes and transforms itself into a round 
ulcer, secreting a sero-pus, which forms a thick crust. 
Untreated the disease continues to spread in the same 
manner. 

2d Form. This is like the first, but its abscesses are 
larger, they heal easily, contain gray-whitish pus, and in 
their cultures is found another species of sporotrichium 
called S. Dori. This is a fungus midway between a 
streptothrix and a trichophyton. 

3d Form. In this, in from one to three months after 
a traumatism, a small cold abscess develops at the point 
of inoculation which leaves a persistent ulceration last- 
ing many months. Some days or weeks after the initial 
lesion a hard nodule appears above it in the course of 
the lymphatic trunk, and so the disease spreads up the 
limb. The nodes undergo softening and ulcerate spon- 
taneously. The lymphatic trunks can be felt like whip 
cords, but the skin is sound and the health unaffected. 
This form is due to the S. Sehenkii, which differs from 
the other two. 



596 DISEASES OF THE SKIN. 

Diagnosis. Syphilis is diagnosed from sporotrichosis 
by having fewer gummatous lesions which undergo a 
slower evolution, and form smaller abscesses. They open 
of themselves, and the ulcers that form have more in- 
filtrated dark red borders, their floor is more uneven, and 
their crusts are green. Their cultures do not show sporo- 
tricha. Mercury cures them, and has no influence on 
sporotrichosis. Blastomycosis affects the health more 
profoundly, its evolution when acute, is attended by 
fever, its abscesses are painful, and it has other skin 
lesions. The organism found in the cultures is not the 
same. 

Treatment. All forms yield readily to iodid of po- 
tassium, 30 to 60 grains a day. 

Stearrhoea. See Seborrhoea. 

Steatoma. See Sebaceous cyst. 

Steatorrhea. See Seborrhoea. 

Stigmasie seu Stigmata. See HaBmatidrosis. 

Stinkschweiss. See Bromidrosis. 

Stonepock. See Acne. 

Striae et Macular Atrophica. See Atrophoderma stria- 
tum et maculatum. 

Strophulus. See Miliaria. 

Strophulus Albidus. See Milium. 

Strophulus Prurigineux (Hardy). See Prurigo. 

Sudamina. See Miliaria. 

Sudatoria. See Hyperidrosis. 

Sudor Urinosus. See Uridrosis. 

Sueurs Colorees. See Chromidrosis. 

Summer Eruption of Hutchinson. See Hydroa vaccini- 
forme. 

Sweating, Excessive. See Hyperidrosis. 

Sycosis. Synonyms : Sycosis non parasitica ; Sycosis 
menti ; Sycosis barbae; Mentagra ; Acne mentagra ; Fol- 
liculitis barbae ; Folliculitis pilorum ; Herpes pustulosus 
mentagra ; Lichen menti ; Acne sycosis ; (Fr.) Sycosis 
non parasitaire ; Dartre pustuleuse mentagre ; Adeno- 



SYCOSIS. 597 

trichie ; (Grer.) Bartfinne, Bartflechte ; Fikosis ; (Eng.) 
Barber's itch. 

An acute or chronic follicular and perifollicular inflam- 
mation of the long hairs, chiefly affecting the bearded 
portions of the face ; characterized by an eruption of 
papules, pustules, and tubercles perforated by hairs ; by 
the formation of infiltrated patches ; and by a greater or 
less amount of crusting. Sometimes the disease is so 
intense that abscesses form. 

Symptoms. The disease begins by the formation of a 
number of red inflammatory papules and tubercles which 
are more or less conical, usually raised above the surface 
of the skin, and always perforated by hairs. Their appear- 
ance is preceded and accompanied by disagreeable local 
sensations, such as pricking, burning, and smarting, and at 
times by a feeling of tension in the part on account of 
swelling of the skin. In acute cases there is considerable 
redness of the skin between the papules, and the inflamma- 
tion may be so intense as to give rise to enlargement of the 
neighboring lymphatic glands. The papules and tubercles 
vary in size from that of a millet-seed to that of a pea, and 
are isolated or grouped, not every hair follicle in a diseased 
part being affected by the perifollicular inflammation. 
Only in very severe outbreaks or in acute exacerbations 
do the papules and tubercles tend to run together and 
form infiltrated patches. 

The pap ales and tubercles soon change into pustules, 
which are likewise always pierced by hairs. These pus- 
tules, conical in shape, and perforated by hairs, are path- 
ognomonic of the disease. In old cases they are met 
with in the infiltrated patches arising apparently without 
the preceding appearance of papules and tubercles. The 
pustules show no tendency to rupture, but the pus accu- 
mulates below, swells up alongside of the hair, appears 
upon the surface of the skin, and dries into thin crusts. 
The amount of crusting is never very great, far less than 
in eczema of the beard, mainly limited to the affected 
follicles, and is most appreciable when the beard is 



598 DISEASES OF THE SKIN. 

growing. If the inflammation is very intense, we may 
meet with small eutaneous abscesses here and there instead 
of pustules. According to A. R. Robinson, the amount of 
pus-production varies with the individual attacked, being 
more rapid and abundant in the robust than in the scrof- 
ulous ; in acute than in chronic cases. 

The hairs, if of any length, are early affected in appear- 
ance, becoming lusterless. They are at first firmly seated 
in their follicles, and when pulled upon give rise to pain, 
and if extracted their root sheaths will appear as clear 
glassy cylinders. Later, as pus forms more abundantly 
in the perifollicular tissues, and the follicles themselves 
are involved in the process, the hair becomes loosened 
and easily extracted, when its root sheath will be found 
swollen with pus If the pus-production is excessive, the 
hairs will fall of themselves or upon the slightest traction. 
When this occurs the hair papillae may be so damaged 
that no new hairs will form. In chronic cases the beard 
is markedly thinned, though permanent loss of hair is the 
exception. 

The disease may attack any part of the bearded face, 
and may be met with in other hairy regions, as the neck, 
the eyebrows, scalp, axilla, and pubes. Occurring else- 
where than on the face the disease is called folliculitis, 
and not sycosis. But the beard is by far most often the 
site of the disease, the other situations being affected in 
the order in which they are named. Occurring in the 
beard, it may be limited to a single region and show no 
tendency to spread. Thus it is met with very frequently 
upon the upper lip alone, or at times upon the cheeks 
alone. When it affects the upper lip alone it is always 
preceded by nasal catarrh, and takes the form of a dif- 
fused dermatitis with much thickening of the lip and 
some crusting. It may attack the whole bearded face in 
an acute outbreak, or it may involve it by extension from 
a limited area during a number of successive outbreaks. 
Very often it spares the chin. In chronic cases it is 
usually symmetrical. The course of the disease is chronic 



SYCOSIS. 599 

and made up of a number of acute exacerbations. If 
left to itself, it may produce a good deal of deformity, 
the tubercles and pustules breaking down, ulcerating, and 
leaving cicatricial tissue and more or less baldness, though 
this is exceptional. To this the name of ulerythema syco- 
siforme has been given. 

A typical case of sycosis presents the following appear- 
ance : upon a single region, two or more regions, or upon 
the whole bearded portion of the face there will appear a 
number of isolated or grouped papules, tubercles, and pus- 
tules pierced by hairs. The skin about the lesions is red- 
dened and swollen, it may be indurated, and there is a 
slight amount of crusting. There is no tendency for the 
disease to spread to non-hairy parts, but very commonly 
the eyebrows will be similary affected, and a blepharitis 
will be present. When the case is watched for a time 
marked exacerbations will arise often without apparent 
cause, last for a few days, and then the disease will sink 
into a subacute condition only to light up again. When 
the disease affects the vibrissas of the nose, by extension 
from the upper lip, the Schneiderian membrane becomes 
swollen and exquisitely sensitive. The patient does not 
complain of itching, but of pain and discomfort. The 
disease tends to run a chronic course, lasting for years. 

Etiology. The disease is undoubtedly microbic due to 
the invasion of the hair follicles by staphylococcus albus 
et aureus. It is not very common, perhaps one case in 
three or four hundred. It is doubtless contagious in some 
cases, and frequently transferred by the agency of the 
barber shop. It is seen in men almost exclusively, as we 
might expect, as it is the beard that is most often affected ; 
and attacks them most frequently between the ages of 
twenty-five and fifty. It affects all classes and condi- 
tions. Most of its subjects are in poor general condition. 

Eczema is often a forerunner of sycosis, the one process 
passing over into the other. A nasal catarrh is the cause 
of the majority of cases occurring on the upper lip. Shav- 
ing with a dull razor against a stiff beard is said to be 



600 DISEASES OF THE SKIN. 

sometimes an exciting cause, though those who do not 
shave are by no means exempt from the disease. An ir- 
ritant applied to the skin may excite it, such as exposure 
to intense heat, the dust of a workshop, cosmetics, poultic- 
ing and the like. Exposure to inclement weather is 
regarded by Wilson as the principal cause. Given a 
liypersemic or irritable condition of the skin of the face, 
arising from any internal or external cause, the hairs, 
especially if they are coarse, may excite the disease, acting 
as irritants when touched or moved. 

Hebra thinks that some cases may be due to an abnor- 
mality in the growth of new hairs. Wertheim ascribed 
the inflammation to irritation of the hair follicle by hairs, 
whose diameter was, relatively, too large for their follicles. 

Pathology The disease is primarily a perifollicu- 
litis, the hair follicles being affected secondarily, and 
after them the sebaceous glands. The hair papillae, as a 
rule, are not destroyed. Tommasoli has described a 
special organism as its cause, which he named bacillus 
sycosiferus foetidus, and has produced the disease in rab- 
bits by inoculating them with pure cultures of his bacillus. 

Diagnosis. The distinguishing characteristic of sycosis 
is the presence of pustules pierced by hairs. It must be 
diagnosed from trichophytosis barbae, eczema barbae, the 
small pustular syphiloderm, acne, and lupus. The differ- 
ential diagnosis of sycosis from trichophytosis barbce is as 
follows : 

Trichophytosis Barb^:. Sycosis. 

Begins as a small scaly spot, a su- Begins suddenly with an outbreak 
perficial ringworm, and gradu- of papules which soon become 

ally involves the deeper parts pustules, each of which at the 

of the hair. start involves a hair. 

Has its favorite seat upon the chin Its favorite seat is the upper lip, 
and the submaxillary region ; and sometimes it alone is in- 

rarely attacks the upper lip. volved. Involves the hairy por- 

tions of the face more generally, 
and is often symmetrical. 
The eruption consists of tubercles The eruption consists of papules 
and nodules which tend to group, . and pustules, each of which is 
and are studded with a number pierced by a single hair, and 

of hairs. The internodular por- they show no disposition to 

tions of the skin often remain group. The intervening skin is 

unaffected, generally reddened, and may be 

diffusely infiltrated; and ab- 
scesses may form. 



SYCOSIS. G01 

Is a deep inflammatory process so Is a more superficial inflamma- 

soon as the hairs become affected. tion. 

Hair is diseased primarily, and is Hair diseased secondarily, and 

twisted, split and broken. May comes away at first with diffi- 

readily be removed by slight culty, causing much pain. 

traction and without pain. Its Later is easily removed and its 

root is often dry. root is swollen with pus. 

Subjective symptoms slight, may Subjectivesymptomsof pricking, 

be only slight pruritus. burning, and tension of the part. 

These are often intense and at- 
tended by swelling of the face. 

Patches of ringworm often present Limited in most cases to hairy 

on other parts of the body, and parts of face. No tendency to 

sometimes the disease extends extend on non- hairy parts of 

upon the neck or face. face or neck. 

Hairs and scales loaded with the The ordinary pus cocci only are 

trichophyton fungus. found. 

Is a progressive disease, and when The course of the disease made up 

cured not liable to relapse. of a num ber of acute outbreaks. 

Liable to relapse. 

The differential diagnosis from eczema of the beard can- 
not be made with so much certainty, and often we must 
remain for a while in doubt as to the true nature of the 
case. At times sycosis is left by a preceding eczema, and 
we may meet with a case in the transition-stage when a 
sure diagnosis would, manifestly, be impossible. A typi- 
cal case of pustular eczema is attended by a far greater 
amount of crusting than is sycosis, and the crust is of a 
more greenish or blackish color. Upon removing the 
crust in eczema a moist and oozing surface will be ex- 
posed, while in sycosis we will do no more than remove 
the tops from a number of pustules. In eczema the pus- 
tules break down more readily than in sycosis, and they 
are not so accurately located about the hairs. In eczema 
the whole surface of the skin is involved, and the process 
tends to extend upon non-hairy parts of the face. While 
exceptionally eczema is confined to the hairy portion of 
the face, this is. always so in sycosis. Eczema itches, 
sycosis does not. The duration of the disease will at times 
help us to a diagnosis, sycosis being far more chronic than 
is eczema. In syphilis, when the beard is involved, we 
will find pustules upon other portions of the body, and 
the history will help us to a correct conclusion. Further, 
the pustules or papules of syphilis are grouped in circles 
and segments of circles, are of a peculiar color, and their 
development is painless and comparatively slow. Acne 
is scattered about the whole face, and is usually met with 



602 DISEASES OF THE SKIN. 

in young persons. Comedones are present, and the pap- 
ules, pustules, or tubercles have no definite relation to the 
hair. The course and history of lupus are so different 
from those of sycosis that it is hardly possible for them 
to be confused. In lupus vulgaris we have the charac- 
teristic brown tubercles, which do not contain pus, are 
not confined to the hairy portions of the face, generally 
begin in early life, and tend to ulcerate or to be absorbed 
and leave behind cicatrices. 

Treatment. The treatment of sycosis is both general 
and local. While many cases will yield to local treatment 
alone, there are quite as many, if not more, which require 
general treatment. The surroundings of the patient must 
be inquired into, and his mode of life, and we should en- 
deavor to put him in as good a hygienic condition as pos- 
sible. He should be advised against exposing himself to 
dust and wind, and then only with his face powdered or 
protected with ointment, and even against smoking, espe- 
pecially in a wind where the smoke blows against the 
face. The proper regulation of the diet is important. 
Many cases will improve if we stop their tea, coffee, hot 
drinks of all sorts, ale, beer, and spirits. If the diges- 
tive process seems at all embarrassed, it is well to put 
the patient on a light diet for morning and evening, and 
direct him to take his principal meal at noon, eating meat 
only at that time. Anything that is known to him to be 
indigestible must, of course, be prohibited. In a word, 
the diet and hygiene of the patient should be regulated. 

What medicines we should administer will depend upon 
the stage of the disease. In the acute stage, when there 
are much swelling and inflammation, a good dose of blue 
pill, calomel, or some other active cathartic is to be 
ordered, to be followed by an alkaline diuretic. When 
pustulation is active the sulphide of calcium or calx sul- 
phurata may do good. Piffard recommends this very 
highly, giving y 1 ^ of a grain two or three times a day. 
I have little faith in this drug. 

Small doses of calomel, ±\ of a grain, three times a 



SYCOSIS. 603 

day, for two or three days at a time, are useful in reliev- 
ing the congestion of the skin. In chronic cases iron, 
cod-liver oil, and other tonics are indicated if there is a 
state of debility. Arsenic is advised in very obstinate 
cases. If indigestion is present, we must address our 
remedies to its relief before we give calcium, arsenic, or 
other remedy for the disease proper, and then we will 
probably have no need of so-called specifics. 

The local treatment must vary with the condition found, 
whether it be acute or subacute, and is more important 
than the general treatment. When the disease attacks 
the upper lip the nose must be examined for evidences of 
catarrh, and that condition treated if found. 

In the management of an acute case of sycosis soothing 
remedies are needed. Hot water should be sopped upon the 
part for some five or ten minutes once or twice a day, and 
this should be followed, if the beard is growing, by the 
use of a simple oil, such as olive oil or sweet almond oil ; 
or if the face is shaved, the zinc oxide ointment or cold 
cream may be used ; or better still, Lassar's paste, as 
follows : 



R Amyli, \ 

Zinci oxidi, J aa ^ 1J ; 



M. 



Vaselini, ad 3J ; ad 32 

Powdering the part with cornstarch, or bismuth and 
talc, after smearing on a little vaseline, w T ill at times give 
ease and comfort. 

In the early stage, if the inflammatory symptoms are 
not very intense, a mild white precipitate ointment will 
sometimes check the disease. Duhring recommends bath- 
ing the face with " black wash" followed by zinc oxide 
ointment with a drachm of alcohol or \ a drachm of 
camphor to the ounce, spread on cloths and bound on ; 
and speaks well of the oxide of zinc ointment with 1 5 to 
30 grains of calomel to the ounce. 

When the disease has reached the pustular stage, and 
there is more or less crusting, the crusts are to be removed 
by the free use of olive oil, or oil of sweet almonds with 



604 DISEASES OF THE SKIN. 

2 per cent, of salicylic acid, letting it soak in thoroughly 
over night and washing the part with soap and warm 
water the next morning. If the crusts are thick, it is a 
good plan to tie up the bearded face in a towel after 
anointing it with oil. After the crusts are gotten rid of, 
the hairs should be pulled out of the pustules and epila- 
tion continued until pustules cease to form. The patient 
must be made to understand that epilation is necessary 
both for the cure of the affection and the salvation of the 
hair. After epilating, the oxide of zinc ointment, Lassar's 
paste, or diachylon ointment is to be used. Shaving is 
recommended, but it seems to me better to content our- 
selves with cutting the hair short. Shaving is apt to 
irritate the skin, and certainly would favor the dissemina- 
tion of the pus organisms. Sulphur in the form of an 
ointment, J a drachm to a drachm to the ounce, or in 
powder, will sometimes do good, but often will prove too 
irritating. Tilbury Fox recommends the use of the fol- 
lowing ointment after epilating : 



R 



Zinci oxidi, 


} 






Zinci carbonat., 


aa 5j : 


aa 4 


Ungt. aq. rosse, 




ad 5J 5 


ad 32 



M. 



Instead of an ointment we may use oxide of zinc, 1 
drachm to the ounce of linseed or other oil. Shoemaker 
advises the application of equal parts of oleate of mercury 
and olive oil. 

In subacute and chronic cases a more active treatment 
is necessary. Here our aim is not so much to allay in- 
flammation as to stimulate the skin. To this end we may 
use the soap and salve treatment of Hebra, which renders 
such good service in chronic cases of eczema (See page 
238.) In some cases better results will be attained by 
the use of diachylon ointment, or Lassar's paste with 10 
or 15 grains of salicylic acid to the ounce. In very 
obstinate cases in which there is much thickening of the 
skin green soap may be kept applied to the part like an 
ointment. When sufficient inflammatory reaction is pro- 



SYCOSIS. 



6.05 



duced emollient measures, as in the acute stage, should 
be used. 

Our success in treating these cases will vary with the 
thoroughness with which the dressings are applied. All 
ointments must be spread on cloths, not on the skin, and 
the dressings must be kept continuously in close contact 
with the affected part. Sometimes a sulphur ointment, 
\ a drachm to 2 drachms to the ounce ; an ointment of 
iodide of sulphur ; the ointment of the ammoniate (gr. 
xv-xxx ad Sj) or the nitrate (5j-ij ad Sj) ? or the red 
oxide (gr. v-xv ad Sj) of mercury will prove useful. 
Robinson recommends the following ointment: 



R Ungt. diachyli (Hebra), 
Ungt. zinc oxidi. 
Ungt. hydrarg. ammon., 
Bismuth, subnitrat., 



aa 31SS; 
3iss; 



aa48 

12 
6 



M. 



He has found cod-liver oil the best local application in 
strumous subjects. 

Behrend has obtained good results by scraping the affected 
parts with the dermal curette and dressing with a simple 
ointment or oil. All abscesses must be opened. In some 
cases the following ointment has given me satisfaction 
after other combinations have failed : 



M. 



Solutions of the bichloride of mercury, 1 to 1000; or 
of resorcin in alcohol 5 per cent, strength, after shaving, 
may be used. Tumenol in 10 per cent, ointment at times 
is excellent. 

Kaposi recommends the following : 



M. 



R Hydrarg. sulph. rubri, 


gr. vij ; 




Sulph. sublimat. , 


3iij; 


12 


Adipis, 


3 iss ; 


ad 48 


01. bergamot., 


q. s.; 


q. s. 


To be kept on constantly. 







£-naphtol., 


gr. xv. ; 


1 


Spt. sapo. viridis, 


3vj; 


24 


Alcobolis, 


giss; 


45 


Bals. peruv., 


3ss; 


2 


Sulph. loti, 


Siiss ; 


10 



606 DISEASES OF THE SKIN. 

The ammonio-sulphate of ichthyol and other drugs 
used by cataphoresis are commeuded. 

Boric acid does good in some cases. To assure against 
a relapse it is necessary to continue making applications to 
the skin for four or five months after apparent recovery. 

The Rbntgen rays have a brilliant curative effect in 
sycosis. They must be pushed to the point of producing 
a slight dermatitis and causing the hair to fall. A me- 
dium tube is to be used at ten inches distance for five 
minutes, and repeated at intervals of four or five days. 
Usually the hair falls after a dozen sittings. It is the 
method of choice. In some cases the disease relapses 
after a time. It is well to use some one of the antipara- 
sitic lotions or ointments while using radiotherapy. 

Prognosis. This is one of the most obstinate of dis- 
eases. Left to itself, when once under headway it shows 
no tendency to get well, and has been known to last 
twenty or thirty years. Even under the most judicious 
treatment it is an obstinate disease, taking weeks or 
months before a cure is effected. Relapses are exceed- 
ingly liable to occur, and these sometimes show a dispo- 
sition to recur at certain seasons. Unless the hair is 
carefully plucked from the inflamed follicles permanent 
baldness may be caused. But the disease is not dan- 
gerous to life, and it is curable. 

Sycosis Contagiosa. See Trichophytosis barbae. 
Sycosis Capillitii seu Framboesia. See Dermatitis papil- 
laris capillitii. 

Sycosis Parasitica. See Trichophytosis barbae. 

Syphilis. 1 Synonyms : Malum venereum ; Lues ; Mor- 
bus Gallicus, seu Italicus, seu Hispanicus, seu Neapoli- 

1 In the description of the syphilides I have followed very closely 
those given by Prof. G. H. Fox in his Photographic Illustrations of 
Skin Diseases, Treat, New York ; and by Prof. R. W. Taylor in his 
Pathology and Treatment of Venereal Diseases, Lea Brothers & Co., 
Philadelphia. To both of these gentlemen I would extend my 
grateful thanks for the permission to use their books that was 
granted to me. 



SYPHILIS. 607 

tanus, seu Indicus; (Fr.) Verole, or Grosse verole; (Ger.) 
Lustseuche ; (Eng.) Bad disorder, Pox. 

Whole books have been written upon this disease. 
Here we can give only a brief outline of the disease, and 
that as it affects the skin alone. For a further account 
of the disease the reader should consult the larger special 
treatises. 

Symptoms. Syphilis may be acquired or hereditary. 
It is acquired by local infection, the first manifestation of 
which is the appearance of the initial lesion, commonly 
called the chancre or hard sore. In probably 90 per 
cent, of the cases this initial lesion is located on the geni- 
tals, and in the vast majority of these its site in males is 
the glans and prepuce. But the initial lesion may be 
found on any part of the body, and within the mucous 
cavities. According to a table of 198 extra-genital le- 
sions compiled by Pospelow, 1 the female breasts were 
affected in 69 cases; the lips in 49 cases; the throat in 
46 cases ; and then in very much less frequency the 
gums, tongue, chin, eyelids, nose, trunk, anus, arms, and 
legs. Some obscure cases of syphilis are due to the ini- 
tial lesion being in the urethra or upon the cervix uteri 
or deep in the throat, and thus escaping detection. 

The initial lesion appears within two to six weeks after 
inoculation with the syphilitic poison ; usually the inter- 
val is less than four weeks ; exceptionally it may be ten 
weeks. This is the period of incubation. Opiuions are 
divided as to whether the initial lesion is a purely local- 
ized lesion or the expression of a general constitutional 
infection that first declares itself at the point of inocula- 
tion. It appears to me that the weight of the argument 
is altogether on the side of the last opinion. The initial 
lesion may assume the form of a scaly patch, a dry or 
moist papule, a superficial erosion, or a circumscribed 
ulcer with perpendicular edge. Induration of the base 
is a characteristic of all forms of initial lesion ; it is 
sharply defined and imparts to the fingers a distinct re- 
1 Arch. f. Dermat. u. Syph., 1889, xxi., 59. 



608 DISEASES OF THE SKIN. 

sistance that may be as firm as cartilage. Commonly it 
is parchment-like. To detect it, the lesion must be 
gently pinched between the thumb and finger. It is 
present coincidently with the appearance of the initial 
lesion or within a few days afterward. It remains for a 
long time after the disappearance of the lesion — for two 
or three months or longer. The secretion from the initial 
lesion, when present, is thin and chiefly serous. The 
duration of the lesion is variable ; it may disappear 
before the outbreak of cutaneous symptoms, but very 
often remains for some time after this event. Unless 
there has been ulceration, no cicatrix will be left. It 
may leave a staining of the skin or an induration. It is 
usually a solitary lesion, though it may be multiple. 
Taylor 1 says it is not uncommon to see from three to 
thirteen chancres which appear successively either due to 
auto-infection, or infection from two individuals. En- 
largement of the nearest lymphatic glands accompanies 
the initial lesion. If on the external genitals, it will be 
those of one or both groins. They become hard, and are 
painless and freely movable. Suppuration is rare, and 
probably the result of mixed infection. A pleiad of 
glands, three arranged in a triangle, is quite character- 
istic of syphilitic infection. In women initial lesions are 
often so small and last so short a time that they are not 
noticed. In them induration is often not noticeable, and 
the diagnosis is much more difficult than in men. They 
are found on the external genitals, within the vagina, and 
on the cervix uteri. 

The initial lesion may at first assume the character of 
the soft sore. This is the result of mixed infection with 
both the virus of syphilis and of the local venereal ulcer. 
The ulcer will after a while become indurated and as- 
sume its proper characteristics. It is in these cases that 
a suppurating adenitis may develop. Modifications from 
location of the initial lesion must also be noted. 1. Of 
the urethra. A chancre may be at the meatus, in the, 
1 Journ. Cutan, Dis., 1906, xxiv., 401. 



SYPHILIS. 609 

fossa navicularis, or deeper parts. At the meatus it at- 
tracts attention by causing a slight impediment to urina- 
tion. The lips are found glued together by a scanty, 
viscid secretion. The normal opening of the urethra be- 
comes lessened by the induration, which usually involves 
the entire circumference of the meatus. If located deeper 
down, it may give rise not only to interference with 
urination, but also to some pain, and later to a muco- 
purulent or purulent discharge like that of gonorrhoea, 
because it causes a urethritis. It may be felt as a hard, 
tender, circumscribed nodule, and be seen, with the en- 
doscope, as a grayish-red erosion of the urethral wall. 
It may give rise to symptoms of stricture. 2. Of the 
anus. A chancre may be without the anus, at its mar- 
gin, or within the anal ring, and usually presents a 
thickened, fissured, ulcerated surface. It is of a pale- 
rose tint, and decidedly indurated. 3. Of the fingers} 
An initial lesion may be seated at any part of the phal- 
anges, but most often at the sides or base of the nail, or 
at its free margin. It begins as a papule, pustule, ex- 
coriation, or fissure, and attracts attention as an obstinate 
hang-nail or fissure ; or as an irregular, deep-red, some- 
what elevated mass that is ulcerated and covered with a 
scanty serous secretion. The finger is apt to be swollen 
at its end. The epitrochlear and axillary ganglia are 
enlarged, and there may be moderate lymphangitis. 
4. Of the lips. This chancre is usually covered with a 
greenish-brown crust, which, when removed, leaves either 
an erosion of little, if any, hardness, or an ulceration of 
cartilaginous consistence. It may begin as a fissure or 
painful excoriation. The lips may be greatly swollen. 
Either the upper or lower one may be affected ; usually 
only one. The submaxillary glands on the side of the 
lesion are commonly first affected. 5.. Of the tongue. 
Here we meet with a hard, circumscribed, flat, slightly 
elevated, dull- red, smooth, pea-sized nodule ; or a round, 

1 An admirable study of these lesions by Dr. R. W. Taylor will be 
found in the Medical Record, 1891, xxxix., 69. 



610 



DISEASES OF THE SKIN. 



sharply defined, fleshy red, raised, hard ulcer. The 
cervical and submaxillary glands are enlarged. 6. Of the 
throat The patient first notices difficulty or pain in 
swallowing, the latter in the region of the tonsils. Then 
the submaxillary and cervical glands become swollen. 
Examination shows an intense, limited or diffused, gen- 
eral or unilateral, brown or dark redness of the pharynx. 
The tonsils are enlarged, hard, and red, and may be 
eroded, and perhaps covered with an ash-colored deposit 
— a false membrane. Or we may find an irregular, hard 
ulcer with gnawed-out edges, and, it may be, crater- 

Fig. 81. 




Chancre of the lips. By the courtesy of Dr. S. D. Hubbard. 



shaped floor covered with dirty-brown or grayish deposit. 
One or both tonsils may be affected. 7. Of the nipple. 
Chancres of the nipple are usually multiple, and may 
take the form of an erosion, a scaly patch, or an indur- 
ated fissure. The size varies from that of a lentil up 
even to three inches in diameter. They are sometimes 
linear, sometimes sickle-shaped along one side of the nip- 
ple, and sometimes completely encircle the nipple. The 
nipple is red or dark, enlarged, hardened, and at times 
flattened. Mastitis may complicate matters. The axil- 
lary glands are enlarged, as are often those along the 
upper edge of the pectoralis major. On healing, the 
initial lesion leaves a flattening of the nipple, and per- 
haps a leaning of it to one side, characteristics that should 
put us on our guard in the examination of wet-nurses. 



SYPHILIS. 611 

About six weeks after the appearance of the initial lesion 
(it may be as early as the twenty-fifth day, or as late as 
the one hundred and sixtieth), we have the stage of erup- 
tion of the so-called secondary syphilides. Usually just 
before the outbreak of the eruption, or shortly after it, 
examination will show a general enlargement of the lym- 
phatic glands, especially the epitrochlear and post-cervical. 
At the time of the eruption, or shortly before, the patient 
may experience certain constitutional disturbances, such as 
severe headache, malaise, pains in the joints, and a rise of 
temperature of moderate extent. In very many cases 
these disturbances either do not exist, or are of so slight 
severity as not to attract the patient's notice. In some 
cases a more or less profound anaemia will manifest itself, 
or the patient will fall into a markedly cachectic condition. 
Either of these may last far into the secondary period of 
the disease. Weakly individuals are more prone to these 
severe constitutional derangements than are the robust, 
and Fournier teaches that they are most apt to appear in 
women. 

The eruptions of syphilis are, for convenience, divided 
into two groups named, respectively, secondary syphilides 
and tertiary syphilides ; or the early and late lesions. No 
hard-and-fast lines can be drawn, as sometimes those 
lesions usually seen late in the disease manifest themselves 
early in its course. The secondary syphilides are tho.se 
that develop during the first two years after infection. 
They are marked by a more or less general and symmet- 
rical dissemination over the whole cutaneous surface; by 
polymorphism ; by running a rather definite course ; by 
implicating the more superficial parts of the skin and 
mucous membranes ; and by leaving little, if any, trace of 
themselves. In these respects they differ from the lesions 
of late syphilis, which are grouped and limited to certain 
regions, are not polymorphic, show less tendency to run 
a definite course, involve the deeper structures, and are 
prone to leave permanent scars. 

The eruptions of secondary syphilis are the erythema- 



612 DISEASES OF THE SKIN. 

tous, the papular, and the pustular syphilide. The first 
eruption of the secondary stage is usually an erythema- 
tous one, the macular syphilide, or the syphilitic roseola. 
Unlike other syphilides, which are all largely composed of 
new cell-growth, this may be a hyperemia without cell- 
infiltration. It may be a general eruption, though usually 
most marked upon the sides of the trunk and flexor 
aspect of the limbs. The macules are about the size of 
a ten-cent piece, or smaller, of a faint rose-red color, 
circular in form, and little if at all raised above the 
skin. At times we meet with annular lesions from dis- 
appearance of the centre of the macule. The lesions, ex- 
cepting in relapsing eruptions, are distinct from each 
other. They become more evident on exposure to cold, 
it being no uncommon thing to see them appear upon the 
patient's body while he is before us stripped for examina- 
tion. After being out for a time their color becomes 
purplish red, changing to a tawny or yellowish red, and 
later to a brownish yellow. In their early stage they 
can be made to disappear on pressure. They either dis- 
appear and leave either no trace or some pigmentation, or 
they develop into papules. They often co-exist with 
papules and pustules. The evolution of this eruption 
usually requires a week or ten days; sometimes it may 
be much less. The duration of the eruption is from 
one to three months if not removed by treatment. Re- 
lapses occasionally occur, and these may be met with as 
late as the end of the first year. Then it is usually 
limited to certain regions. It gives rise to no incon- 
venience, and is often overlooked by the patient except 
when it appears on the face or hands. At this time there 
are apt to be an erythematous condition of the pharynx, 
some sore-throat, a rheumatoid affection of the joints, 
falling of the hair, and, perhaps, an iritis, and mucous 
patches in the mouth, upon the vulva, in the groin, upon 
the scrotum and under surface of the penis, and about 
the anus. 

While the diagnosis is easy, if we have seen the patient 



SYPHILIS. 613 

from the time of the initial lesion, in some cases we must 
differentiate between it and mottling of the skin ; an 
exanthem ; a medicinal eruption, chromophytosis ; and, if 
we have annular macules, trichophytosis corporis. From 
mottling of the skin it is diagnosed by the fact that in 
syphilis we have macules of a reddish tint interspersed 
with skin of normal hue, while in mottling we have light 
macules with dull purplish-red interspaces. From an 
exanthematous fever it is diagnosed by the absence of 
catarrhal or gastric symptoms and marked pyrexia, and by 
the sluggish character of its lesions. From a medicinal 
eruption it is diagnosed by an absence of gastric disturb- 
ance, and by its lesions lacking the urticarial or cedematous 
character. From chromophytosis it differs in having a 
red rather than a cafe-au-lait color, by not being scaly nor 
capable of removal by scraping, by its more extensive dis- 
tribution, and by the absence of the microsporon furfur 
from the scales when they are examined under the micro- 
scope. From trichophytosis it differs in the greater extent 
of its distribution, and in the absence of the trichophyton 
fungus from scales scraped from the skin. From pityri- 
asis rosea the differentiation is sometimes difficult when the 
syphilitic macules have assumed a ring- form. As a rule, 
there is no difficulty, as a pityriasis rosea will be scaly, and 
will present not only rings, but macules of all sizes, while 
the syphilitic macules are not scaly and are of more 
uniform size. 

The papular syphilide, while usually following the ery- 
thematous syphilide, may be the first eruption of the dis- 
ease. Indeed, a great many cases begin as a maculo- 
papular eruption. The papules may develop from macules 
or may appear as papules. Very commonly both macules 
and papules will be present at the same time. If it fol- 
lows the macular form, it is apt to appear while the 
latter is fading. The eruption consists of a greater or less 
number of firm, rounded, fleshy, red elevations of the skin, 
varying in size from that of a pinhead to one inch in 



614 DISEASES OF THE SKIN. 

diameter. After continuing unchanged for a certain time 
they undergo absorption ; the oldest or central part of the 
papule disappears first, sinks in a little, and becomes scaly. 
It is then that slight pruritus may be complained of. 
They are scattered over the whole cutaneous surface, and 
often appear in well marked groups with somewhat of a 
crescentic arrangement. They are prone to relapses, and 
sometimes are seen as a relapsing eruption in the tertiary 
stage of the disease, when they do not occur as a general 
eruption, but in groups upon one or more regions of the 
body. According to their size, they have received the 
names of the lenticular and miliary papular syphilide, 
the former being the larger and most common eruption. 
The lenticular papular syphilide is a hemispherical or 
flattened, firm, fleshy, lentil- to split-pea-sized promi- 
nence with a smooth and glossy surface. Not infrequently 
the superficial layer of epidermis over it is wanting from 
the central portion and slightly detached around the base, 
forming a fringe called the collarette of Biett. This is 
regarded as a diagnostic symptom. The color of the pap- 
ule is at first light red ; later it assumes a raw-ham color 
that is best seen on the legs. From the knee down it 
may have a purplish or hemorrhagic appearance. Such 
papules are usually present in great number and scattered 
over the whole body. On the face they are apt to locate 
along the hair-line on the forehead, forming the corona 
veneris. On the scalp they are not very numerous, and 
are apt to become papulo-pustules and crust ; or they itch 
slightly and are scratched. The palms and soles are 
usually well covered in any general outbreak of them. 
Here they appear as reddish spots under the thick epi- 
dermis, and a little later than on the rest of the body on 
account of the thickness of the epidermis retarding their 
outbreak. Desquamation is often seen over the papules 
on the palms and soles. Sometimes the eruption is very 
slight in extent, only a few scattered papules being found. 
This syphilide develops slowly, runs a course of one or 
two months, and disappears, leaving pigmentation or 



SYPHILIS. 



615 



slightly depressed spots, neither of which is permanent. 
In undergoing resolution the papules may become scaly 
and form a papulo-squamous syphilide, or pustules may 
form on them during their course, and we then have the 
papulo-pustular syphilide. 

While the form of the lenticular syphilide just described 
is the typical one, we see at times larger papules, from 
three-eighths to half an inch in diameter, forming the 

Fig. 82. 




Papular syphilide of palms. By the courtesy of Dr. S. D. Hubbard. 

large, flat, papular syphilide. This rarely, if ever, is a 
general eruption, but is limited to certain regions. It 
may occur alone or with the lenticular syphilide. It usu- 
ally follows the latter or appears when it is fading. It 
frequently comes as a relapsing syphilide, and often ap- 
pears late in the second year. It has a flattened surface 
and a circular outline. The lesions often coalesce and 
form patches which frequently become scaly and resem- 
ble psoriasis. The scaling is never very great ; the scales 
are thin and adherent, and do not cover the whole patch. 



616 



DISEASES OF THE SKIN. 



They frequently occur upon the flexor aspect of the ex- 
tremities and in the bends of the joints. Instead of 
forming patches by coalescence, the individual papule may 
enlarge at the circumference and become depressed at the 
centre and form circinate lesions, whose surface may 
become moist. 

The moist papule or mucous patch is a modified form 
of the lenticular papule, and is simply a papule subject to 
heat and moisture. It is found where two folds of skin 
rub together, as in the peno-scrotal fold, between the 

Fig. 83. 




Condylomata lata. (After Tayok.) 

scrotum and inside of the thigh, around the anus and 
vulva, and upon mucous membranes. It is of circular 
shape and has a flattened surface which is sometimes de- 
pressed in the centre. Newly formed ones have a bright- 
red or raw appearance, but they soon become covered 
with a dirty whitish coating made up of thickened and 
softened epidermis. About the anus and vulva they form 
large flattened tubercules called condylomata lata. (Fig. 
84.) They give forth a most offensive odor when not 
kept clean. When in the mouth they form "opaline 
patches," looking as if the mucous membrane had been 
penciled with nitrate of silver. They are usually not 
elevated. If at the angle of the mouth, they are generally 
fissured. The mucous patch is one of the most conta- 



SYPHILIS. 617 

gious of syphilitic lesions, the evidence of infection being 
an initial lesion of syphilis, and not a mucous patch. It 
is also at times, especially when it comes late in the dis- 
ease, most obstinate to treatment, and inclined to relapse 
during many years. 

The miliary papular syphilide is much rarer than the 
other form of papular syphilide ; in fact it is one of the 
least common of the syphilides. The eruption consists 
of numerous pinhead- or slightly larger sized conical pap- 
ules of a purplish -red hue, either disseminated over the 
whole body or aggregated in groups forming circles or 
segments of circles. They are developed about the hair 
follicles and have depressed centres. Many of them may 
be surmounted by a small vesicle or vesico-pustule. This 
constitutes what has been named the vesicular syphilide. 
Sometimes the lesions when closely pressed into patches 
may be scaly. It may be an early lesion or a relapsing 
later one. In the latter case the eruption is not abundant, 
but in groups. The color is brownish-red, and pigmen- 
tation and permanent pitting are left by the lesions, if 
they have lasted any time. They rarely change into con- 
dylomata. Their evolution is rapid, being fully devel- 
oped within two weeks. Pea-sized conical papules some- 
times are seen among the miliary ones. 

When the papules form groups bearing a fancied re- 
semblance to a bunch of grapes they are spoken of as 
corymbiform. 

The diagnosis of the papular forms of syphilis is gen- 
erally easy because other symptoms of the disease will be 
sure to be present and to establish the diagnosis. It is 
possible that error may arise in distinguishing the patches 
of scaling papules from psoriasis, but here the location of 
tha patches upon the flexor surfaces of the extremities, 
and over the bends of the elbows ; the scaling not being 
commensurate with the patch, but having a dull red, 
sharply denned border about it ; and the well-marked in- 
filtration of the patches, are all features that would throw 
out the diagnosis of psoriasis. The miliary papular syph- 



618 DISEASES OE THE SKIN. 

Hide may be confounded with lichen planus or keratosis 
pilaris j but the absence of itching is always in favor of a 
syphilide ; and the conical or rounded shape of its pap- 
ules is in strong contrast with the flat, angular, and um- 
bilicated papule of lichen planus. The syphilide is also 
a much more widely disseminated eruption than is lichen 
planus or keratosis pilaris likely to be, and is never seen con- 
fined to the anterior face of the wrists as is lichen planus. 

The pustular syjihilide is the last eruption belonging to 
the secondary stage that remains to be described. It is 
always evidence of a poor condition of the health of the 
patient who bears it. It may be the first eruption of 
syphilis, or follow the erythematous or papular form, or 
occur later. It may develop from a macular or papular 
syphilide, or occur with either of them. It may occur as 
a relapsing eruption late in the tertiary period. It is held 
by some authorities that it is always the product of infec- 
tion of a syphilide by pus-organisms. The appearance of 
this form of syphilide is not infrequently accompanied by 
fever. It may assume varying forms and sizes, to which 
in the faulty nomenclature of the older writers have been 
given the names of non-specific lesions, greatly to the con- 
fusion of the student. Dr. George H. Fox has done 
well in discarding all such terms, and in describing two 
forms, the lenticular and the miliary pustular syphilide. 

The lenticular pustular syphilide (variola-form) occurs 
as a disseminated eruption of small hemispherical, pea- 
sized pustules, having a hard, papular base and more or 
less of an inflamed areola. It may develop by the soft- 
ening of a papule or be a papulo-pustule from the start. 
In the latter case its eruption will be marked by fever, 
which is apt to recur with each succeeding outbreak. The 
eruption may be general or upon certain regions. The 
lesions are discrete, and do not form marked groups, 
although in the pustular eruptions, as in others, it is easj 
for one who looks for them to find groupings in circles 
and segments of circles. A few days after they appear 
they begin to dessicate, and the larger ones may umbili- 



SYPHILIS. 619 

cate. At this stage they become crusted with a dirty- 
yellow, brownish, or greenish-brown crust. This falls 
soon and leaves a transient pitting and pigmentation. 
Relapses may occur. 

The miliary pustular syphilide (acne-form). The erup- 
tion consists of millet-seed- to pinhead-sized acuminate pus- 
tules developing generally from papules and occurring in 
small groups of about the size of a quarter- or half-dollar. 
It may occur as a general eruption, but is apt to be more 
marked and lasting on the extremities than on the trunk. 
The lesions, especially when occurring upon the flexor 
aspect of the joints, are liable to coalesce. They are devel- 
oped in and around the hair follicles, and may be perfor- 
ated by hairs. They are topped with small crusts. The 
eruption lasts two or three months by the outbreak of new 
lesions, unless controlled by treatment. It leaves pigmen- 
tation and pitting that may remain for several months. 

While these are the two chief varieties of the early 
pustular syphilide, there is another variety that is called 
the impetigo-form syphilide, which occurs most commonly in 
the middle or latter part of the first year of syphilis. It 
may occur as late as in the third year. In it the pustules 
are small and flat, and by confluence an impetiginous crust 
is produced. They may form patches with crusting only 
at the border. This form is met with usually on the face, 
arms, and thighs. A few superficial ecthymatous lesions 
may develop, but ecthymatous lesions are usually late 
manifestations. 

The dieignosis of the pustular syphilide is usually easy 
from the presence of other symptoms of the disease. The 
lenticular form may be mistaken for variola or vetrioloid. 
It differs from these in the infiltrated bases of the pustules, 
in being composed of lesions of varying size and age, in 
not occurring in the mouth, and in not running a definite 
rapid course. The miliary form might be mistaken for 
acne, but it is never confined to the face, chest, and back 
as in acne, nor does it present comedones, and so great 
multiformity of lesions. 



620 DISEASES OF THE SKffl. 

Tertiary Syphilides. The erythematous, papular, and 
pustular syphilides are those eruptions that occur in the 
early months of syphilis and during the first year. As 
we have seen, they may also constitute relapsing eruptions 
later in the disease. Modifications of them may occur 
late in the secondary period or even in the tertiary period. 
Besides these, we have a second group of syphilides that 
occur any time after the first year, and sometimes as late 
as twenty or more years after the initial lesion, when the 
patient may have lost all remembrance of it. To these 
eruptions the name of tertiary or late syphilides is given. 
Their peculiarities have been indicated in a general way 
when writing of the early syphilides. They are the tu- 
bercular, the squamous, the pustulo-crustaceous, the gum- 
matous, and the ulcerative syphilides. Exceptionally these 
eruptions may occur before the second year, when they 
are to be regarded as precocious lesions. 

The tubercular syphilide occurs in the latter part of the 
second year of syphilis, or later. Exceptionally it may 
occur during the first year as a so-called precocious syph- 
ilide. As a rule, the early syphilides cease appearing 
after six or seven months, and then after a varying inter- 
val of rest the late lesions appear. These may never 
come at all, usually as the result of judicious treatment, 
or it may be because of the vigorous resistance of the 
constitution of the individual. Tubercular lesions occur 
in the form of clustered nodules in the deeper part of the 
corium. At first they are of faint-red color ; gradually 
they become a dull red, and later still darker. In size 
they vary from that of a split pea to that of a hazelnut, 
and constitute firm, elastic, fleshy protuberances. They 
are round, smooth, and somewhat glossy, or flat, rugous, 
and withered. They are frequently scaly. Most often 
they are arranged in circles or segments of circles ; or 
they may be in the form of rings from the first, or in con- 
sequence of the disappearance of the central members of 
the group (Fig. 86.) There may be but a single group ; 
or numerous groups may be scattered over the body in a 



SYPHILIS. 621 

symmetrical manner. A very frequent location for them 
is the posterior portion of the neck or on the face. The 
later in the course of the disease they occur, the more 
they are apt to form but a single group. If uninfluenced 
by treatment, tubercles may continue to form for years, 
the old ones disappearing and new ones coming. They 

Fig. 84. 




Annular tubercular syphilide. (After Taylor.; 



disappear either by absorption, or by softening or break- 
ing down and forming a sharply-cut ulcer with perpen- 
dicular edges and yellow sloughing base. A number of 
the lesions breaking down at once and coalescing, a large 
ulcer with scalloped border, indicating its composition 
from single lesions, and with more or less thick greenish 



622 



DISEASES OF THE SKIN. 



crust, will form. In either case they leave depressed, 
smooth cicatrices, at first pigmented, but later white. 
They give rise to no subjective disturbances. Rarely do 
they form a general eruption. 

The diagnosis of this form of syphilide is usually read- 
ily arrived at by finding other symptoms of syphilis. Oc- 
casionally it may be confounded with lupus vulgaris and 
leprosy. From lupus it is differentiated by the compara- 
tive rapidity of its course, lupus being a disease of exceed- 
ing slowness of development ; by its occurrence in mature 



FiG. 85. 




Tubercular syphilide. (By the courtesy of Dr 



Hubbard.) 



years, lupus beiug a disease of youth ; by its sharp-cut 
round ulcers by ; its thick greenish crusts, and by the 
smoothness of its cicatrices, those of lupus being puckered 
and deforming. Syphilis at times bears a striking re- 
semblance to leprosy when its tubercles are located in the 
eyebrows, face, and ears, but the absence of anaesthesia is a 
positive diagnostic sign against leprosy. Moreover, other 
symptoms of leprosy, such as swelling of the ulnar nerves 
and peculiar brown patches, will be absent. 



SYPHILIS. 



623 



The squamous syphilide is not usually described, as it 
is a modified form of either the papular or the tubercular 
lesiou. Iu using the term here, I follow Dr. George H. 
Fox, and like him adopt it purely on clinical grounds. 
He applies the term to scaly patches of circular or irreg- 
ular form that occur after the first year of syphilis. 
These patches are covered with thin horny scales seated 
upon an infiltrated base. We may have one of two 




The circinate squamous syphilide. (By the courtesy of Dr. S. Dana 
Hubbard.) 

forms : the discoid or the circinate. The discoid form is 
almost peculiar to the palms and soles and neighboring 
parts, and constitutes the only apparent lesion. The 
round patch of varying size, but with a sharply defined 
reddish seam beyond the scaling, and an infiltrated base, 
tends to become serpiginous, creeping over a considerable 
portion of the skin. Sometimes while it advances at one 



624 DISEASES OF THE SKIN. 

border it heals at the other ; at other times it clears up in 
the centre, leaving an elevated, scaling marginal ring. 
The ring may be broken and leave a curved line, and if 
two or more of these lines meet, we have a gyrate figure. 
Usually but one palm or sole is involved. The skin is 
apt to crack in the natural creases, and then the patient 
will suffer some pain and discomfort. It is always an 
obstinate lesion to cure, persisting sometimes for months 
or years. The eircinate form differs from the one just 
described in being annular from the first, and in occur- 
ring not only on the palms and soles, but elsewhere on 
the body. It is often seen on the face, about the mouth 
and chin, and seems to be specially apt to affect the 
negro race. A seborrhea sicca frequently complicates it. 
Unna teaches that the lesion is a combination of sebor- 
rhea and syphilis. 

The diagnosis of this form of syphilide from a squam- 
ous eczema of the palm is often one of great difficulty. 
The fact that only one palm is affected is always sugges- 
tive of syphilis. Moreover, in syphilis there are more 
infiltration and much less itching. Indeed, the latter 
may be entirely absent. In syphilis the lesion is often 
crescentic, with sound skin between the horns of the 
crescent. This is never seen in eczema. Psoriasis of 
the palm is in most cases not to be thought of as a stum- 
bling-block in diagnosis, as it is exceedingly rare for 
psoriasis to affect the palms, and then only as a part of a 
general outbreak of the disease t Some writers use the 
term syphilitic psoriasis for the scaly palmar syphilide, 
but it is a most faulty method of nomenclature. 

The pustulo-erustaceous syphilide is characterized by 
large and usually deep-seated pustules or ulcers, covered 
by prominent and peculiar crusts. It is the ecthyma- 
form of R. W. Taylor and other authorities. It occurs 
as a late and localized form of the disease ; never as a 
general eruption. It may occur as a precocious syphilide. 
It is seen in debilitated subjects, and is of gradual de- 



SYPHILIS. 625 

velopment, without febrile symptoms as in the pustular 
syphilide. It has preference for the scalp, face, and ex- 
tremities. It assumes three forms, the ecthymatous, 
rupial, and pemphigoid. 

The ecthymatous form begins as an eruption of one or 
more round, flat pustules of a diameter of one-quarter to 
one-half inch. They may become as large as a silver 
half-dollar. They have a well-marked inflammatory 
areola and a swollen and indurated base. The pus soon 
dries and forms a flat, greenish or brownish-black crust, 
whose centre is sometimes depressed. At first the crust 
fully covers the pustule, but later, either through drying 
or on account of an increase in the size of the pustule, a 
raw rim is left around it. When it is now removed it 
exposes a typical punched-out ulcer with its base covered 
with sanious pus, which rapidly dries into a new crust. 
Under proper treatment the pustule heals, and when the 
crust falls there will be left a healed or nearly healed 
ulcer. A permanent cicatrix is left when healing is com- 
pleted, which is smooth and white eventually. This 
syphilide is seen most often on the legs and arms. If the 
course of the disease is not checked, the crust is cast off 
by increased suppuration, and the ulcerative syphilide is 
before us. 

The second variety of the pustulo-crustaceous syphilide 
is that which is commonly known as rupia. It differs 
from the preceding variety in being more superficial at 
the beginning, and in forming a conical, laminated crust 
somewhat resembling an oyster shell. It begins either 
as a superficial pustule or as a small flattened bulla with 
no inflammatory induration. Upon the primary lesion a 
greenish crust develops, under which ulceration, with 
suppuration, occurs. The margin of the ulceration ex- 
tends a little beyond the original crust. A new crust 
forms upon it, raising up the original one, and this pro- 
cess being repeated, at last a laminated crust is raised. 
When the ulceration extends more rapidly in one direc- 
tion than another it follows that the crust will be higher 



626 DISEASES OF THE SKIN. 

at one end than at the other. Crusts may form a half- 
inch or more in height, and one or two inches in diameter. 
If the lesions are numerous, they are usually small ; if 
few, large. When these thick conical crusts are re- 
moved, the ulcer is exposed and is less deep than in the 
ecthymatous form. On healing, a permanent, smooth, 
white cicatrix is left at last. 

The third variety of the pustulo-crustaceous syphilide 
is the pemphigoid or bullous form. It is a very rare 
lesion in acquired syphilis, though quite common in 
hereditary disease. It consists in an eruption of superfi- 
cial, purulent, flattened bulla? from 1 to 5 centimeters in 
diameter, which tend to dry into thick crusts. They are 
surrounded by a dull-red areola, and are soon covered by 
dark greenish-black adherent crusts. If the patient be 
in fair health, the ulceration under the crusts will not be 
deep. If the patient be a broken-down subject, the 
ulceration may be very deep. It will leave either a 
pigmented atrophic spot or a pronounced scar, according 
to the depth of the ulceration. 

The diagnosis of the pustulo-crustaceous syphilide is 
usually easy if the disease is known to the observer, as 
no non-specific disease resembles it closely. The so-called 
ecthyma cachectieum is more inflammatory than is the 
ecthymatous syphilide, and more superficial. The bullous 
syphilide often bears a striking resemblance to pemphigus, 
and can be diagnosed only by a study of all the features 
of the case. 

The gummous syphilide is perhaps one of the most char- 
acteristic of the late lesions of syphilis. It consists in a 
deposit of gummy material in the skin. The distinction 
between some tubercular lesions and a gumma is often 
very indistinct, and made principally by the size. The 
gumma begins in the subcutaneous tissue and involves the 
skin secondarily. It may take the form of a single tumor, 
a group of nodules, or a diffused infiltrated patch. It is 
nearly always a late lesion, and while it niay undergo 



SYPHILIS. 



627 



Fig. 87. 



absorption it possesses a strong tendency to break down 
and ulcerate. (Fig. 87.) 

The single tumor begins as a small pea-sized nodule, 
seated in the subcutaneous tissues so deeply as to be 
appreciated only by the touch. It grows slowly ; in the 
course of weeks or months it may attain the size of a nut 
and push up the skin over it 
into an evident tumor, which is 
movable, firm, elastic, painless, 
and rolls under the finger. In- 
creasing in size, it involves the 
skiu, which then becomes of a 
dull-reddish color. When the 
skin becomes involved the tumor 
is no longer movable, and soon 
fluctuation may be felt that 
would lead the inexperienced to 
open it as an abscess. If he did 



so, it would be a mistake. He 



would find only a 
gummy substance, 




little pus, a 
aud some 
blood. Left to itself, the tumor 
may be absorbed, or it may 
break down and ulcerate, leav- 
ing a characteristic deep and 
round ulcer. The scalp and fore- 
head are the chosen sites for this Gumma ta. (After jttlmen.) 
syphilide, though it may occur 

anywhere. It sometimes attains a large size — as large as 
a hen's egg. When this lesion occurs as a precocious 
syphilide it is usually of small size and multiple. 

When gummata occur in the form of grouped nodules, 
the skin between them is apt to become infiltrated with a 
gummatous deposit, and the patch will present the dull 
brownish-red color of the late syphilides. The individual 
members of the group run a course similar to that of the 
isolated gumma, but do not attain its size. When they 
break down they form a large irregular ulcer. This va- 



628 DISEASES OF THE SKIN. 

riety of the gumma is frequently met with upon the 
scalp, the nose, the outer aspects of the extremities 
about the joints, and around the lower portion of the leg 
and ankle. Diffuse gummatous infiltration of the skin 
probably precedes all serpiginous ulcerations. Apart from 
this it is rarely seen, and almost always ends in ulcer- 
ation. 

Other gummatous deposits are known as syphilitic dac- 
tylitis, admirably described by R. "W. Taylor, and syph- 
ilitic bursitis, carefully studied by E. L. Keyes. One 
being a bony and the other a synovial disease, they do 
not here concern us. 

The diagnosis of the gumma must be made with care. 
It may simulate other forms of tumors. It is not as hard 
as the sarcoma, nor as compressible as the lipoma, and it 
invades the skin. An abscess is usually attended by pain 
and signs of inflammation, and runs a more acute course 
than does the gumma. 

The ulcerative syphilide, according to Dr. George H. 
Fox, merits being described by itself, though in itself only 
a sequence of a tubercular, pustulo-crustaceous, or gumma- 
tous syphilide, because in the majority of cases of 
syphilitic ulcers met with it is hard or impossible for 
us to say what the preceding lesion has been. For con- 
venience, he describes the superficial, the serpiginous, and 
the deep or perforating forms of syphilitic ulceration. 

The superficial syphilitic idcer is circular, with sharply 
cut edges and dirty-yellowish purulent base. It most often 
follows a pustular or pustulo-crustaceous lesion, and may 
appear comparatively early in the disease, especially in 
debilitated subjects. It is usually of the size of a quarter- 
or half-dollar, and frequently coalesces with other ulcers to 
form ulcerative patches with scalloped margins. The face 
and legs are its most common sites. 

The serpiginous ulcer is so called because it tends to 
creep over the surface, healing by a cicatrix as it passes 
along. It may develop from a single circular ulcer heal- 



SYPHILIS. 629 

ing in the middle or at one side, and leaving a crescentic 
or "horseshoe" ulcer at the other side, with a sharp 
convex margin, beyond which is a narrow zone of infil- 
tration upon which the ulceration constantly encroaches, 
while healing at its concave border. Or a group of 
crusted pustules or softening tubercles form a number of 
small round ulcers, of which the outer ones usually form 
a curving line. While those in the centre and at one 
side tend to heal, new lesions develop at the periphery 
of the opposite side, which ulcerate and perhaps coalesce, 
and so the disease creeps on. This form is often observed 
upon the back and on the extremities; it is not par- 
ticularly painful, and the patient's health may not be 
impaired. 

The deep ulcerations of syphilis result, for the most part, 
from the breaking down of gummatous deposits. The 
small ones are crater-like in shape. Often the opening of 
the softened tumor is smaller than the softened mass, and 
it is not infrequent to find the cavities of adjacent tumors 
running together subcutaneously. 

Ulcerative syphilides sometimes are covered with exu- 
berant granulations. 

The diagnosis of syphilitic ulcers from non-specific 
ulcers is most important from a therapeutical standpoint. 
A chronic ulcer, if it is not syphilitic, is probably either 
traumatic, tubercular, or cancerous. The traumatic ulcer 
is acute and highly inflammatory ; of irregular shape ; 
has a history of traumatism ; and heals rapidly, except- 
ing in very broken-doAvn subjects, under simple dress- 
ings. The tubercular ulcer, if from broken-down caseous 
glands, has a history of the previous glandular affection ; 
is irregular in shape ; often presents a number of sinuses 
and ridges of inflamed tissues ; and runs a sluggish 
course. If it is a lupous ulcer, there will be found some- 
where in the neighborhood the characteristic apple-jelly- 
like tubercles ; there will be a history of commencing in 
early life ; the edges of the ulcer will be shelving or un- 
dermined ; and there will usually be more or less deform- 



630 DISEASES OF THE SKIN. 

ing cicatrices present. A cancerous ulcer, usually an 
epithelioma, will have a history of beginning in a pimple, 
wart, mole, or such like ; will be irregular in shape with 
an uneven floor ; will be apt to be attended by lancinating 
pain ; will usually be a single lesion, located on the face ; 
and will have a raised, waxy, rolled-out border over 
which delicate bloodvessels will be seen to course. 

The diagnosis of ulcers of the leg lies between one of 
syphilis and of varicose dermatitis. If the ulcer is irreg- 
ular in shape with shelving edges, rather superficial, sur- 
rounded by a brawny, infiltrated, brownish or dark-red 
tissue with more or less scaling, and there are varicose 
veins above it, we have to do with the so-called varicose 
ulcer. This is in sharp contrast with the round or scal- 
loped bordered, deep, punched-out ulcer with perpendicu- 
lar edges and greenish base, around which there is but a 
small zone of redness. The diagnosis of syphilis is 
strengthened when we find a number of ulcers, or the 
cicatrices .of old ulcers. As a rule the syphilitic ulcer is 
located on the posterior surface of the upper half of the 
leg, while the varicose ulcer is on the anterior surface of 
the lower third of the leg. The diagnosis from a trau- 
matic ulcer has already been given. 

Over the pigmentary syphilide there has been no little 
discussion. By this term is not meant pigmentation fol- 
lowing a syphilide, which is sufficiently common, and due 
to a staining of the skin with hamiatin, but a true pig- 
mentation without antecedent lesion, which is sometimes 
seen on the sides of the neck, especially in women. It is 
composed of irregularly round or oval spots, one-eighth 
of an inch to one inch in diameter, with ill-defined mar- 
gins, and cafe-au-lait color, which does not fade on pres- 
sure. The color may be very faint. The lesions may be 
discrete or confluent. When they are very numerous 
they have been compared by Fournier to a " network 
of lace with large meshes," and to it has been given the 
name of collarette of Venus. This is one of the rarer 
manifestations of syphilis. 



SYPHILIS. 631 

Alopecia due to syphilis has already been described 
under the heading of Alopecia Syphilitica, which see. 

Syphilitic affections of the nails may be due to lesions 
of the nail-bed or matrix or both ; or of lesions about the 
nail. In the first variety the nails are damaged in their 
nutrition, becoming brittle, furrowed, discolored, and 
broken ; or they may become detached from the bed and 
fall. They may become thickened, but less commonly. 
In the second variety we have a perionychia, the nail 
furrow becoming swollen or perhaps ulcerated. 

General Diagnosis of Syphilis. One marked 
feature of the cutaneous lesions of syphilis is that they 
do not itch. Itching does occasionally occur with the 
scaling papular and crusted syphilides, when it is due to 
the irritation of the nerves by the crust or scale, and in 
some cases the patient will complain of an itching of the 
skin which is quite independent of syphilis, but in them- 
selves they do not itch. 

The early eruptions of syphilis are general and exhibit 
a marked polymorphism, many different lesions being 
often present at the same time ; as, for instance, macules, 
papules, and pustules. The late eruptions exhibit a 
strong tendency to grouping of the lesions in circles and 
segments of circles, and one characteristic of the circles is 
that they are seldom complete, but broken somewhere 
in their outline. 

The color of the lesions is peculiar, and perhaps may 
be best described as that of raw ham, though the classic 
term is " copper." This color is by no means always 
present. It is not seen in the early bloom of the early 
lesions, but is pretty sure to be found in those that have 
existed for some time, and in the late lesions. The color of 
a lesion on the legs, it must be remembered, must not be 
regarded for purposes of diagnosis ; it is upon the arms, 
face, trunk, and thighs that we must look for the charac- 
teristic color. 

Painlessness is often a suggestive symptom pointing 



632 DISEASES OF THE SKIN. 

toward syphilis when we have to decide as to the nature 
of an ulceration. 

It is well not to lay too much stress upon the history 
of the case in making up our mind as to a late syphilide, 
because with the best intentions the patient may forget 
having had an insignificant initial lesion some twenty, or 
perhaps thirty, years before. 

Space will not permit of our here detailing the differ- 
ential diagnosis between syphilis and the many diseases 
which it may simulate from time to time. For this the 
reader must be referred to the sections upon eczema, 
psoriasis, lupus, alopecia, etc. 

Etiology. That acquired syphilis is due to contagion 
we know. After many unsuccessful attempts Neisser 
and others, have succeeded in inoculating apes with the 
disease by deep scarifications and the insertion of material 
taken from active lesions. 

Schaudinn, Hoffman, and many others have found 
spirochceta pallida in syphilitic lesions. The spirochseta 
pallida is a corkscrew shaped organism, very slender, 
4 to 10 microns long, with 6 to 14 spirals, and actively 
motile by rotation on its long axis. It has been found 
in the fluid expressed from syphilitic lesions, primary, and 
secondary, both superficial and deep, congenital and 
acquired, and in smaller number in gummata. This 
spirochete has been demonstrated so frequently by numer- 
ous observers that little doubt can exist as to its speci- 
ficity in the causation of syphilis. 

Pathology. With the exception of the roseola 
whose pathology is that of any toxic erythema, all the 
various syphilitic lesions are histopathologically similar. 
The papule may be taken as the type of syphilitic cutane- 
ous lesion, from which the other forms differ only in 
extent, severity and secondary accidents. . 

The papule is composed of a dense granulomatous in- 
filtration of the papillary layer of the corium, with small 
round cells, among which plasma cells are abundant and 
mast cells present in considerable number. The infiltra- 



SYPHILIS. 633 

tion first follows the course of the bloodvessels, and 
appears to be secondary to an endarteritis and endophle- 
bitis, though the latter is not so conspicuous as the arte- 
rial changes. New capillaries invade the infiltration 
and a moderate diapedesis from these gives to the gross 
lesion its characteristic raw ham color. The collagenous 
connective tissue bundles are increased in size and num- 
ber, and enclose in places groups of plasma cells which 
occasionally take on the form of giant cells. The infil- 
tration undergoes a fatty degeneration, or a coagulation 
necrosis due to the obliterating endarteritis, with subse- 
quent absorption or ulceration. There is never any 
attempt at organization into connective tissue. The over- 
lying epithelium is affected only secondarily. 

Hereditary Syphilis. This differs from the acquired 
form in having no initial lesion, the disease being ac- 
quired in utero from either one or both parents. We 
cannot enter upon a discussion of the many conflicting 
theories as to whether or not the child is diseased on 
account of springing from a diseased ovum, or sperm- 
atozoa ; or the possibility of the disease, acquired by the 
mother after her pregnancy, reaching the foetus through 
the placental circulation; or like interesting questions 
over which the battle rages. For us now it suffices to 
make the bald statement that the disease may be acquired 
from one or both parents. It is most sure to be acquired 
from the mother, and it may be inherited by the foetus 
from a mother infected some months after conception. 
It is possible for a woman to show no signs herself of 
syphilis, and yet to give birth to a syphilitic child. It 
is exceedingly rare for the apparently healthy mother of 
a child hereditarily syphilitic to be infected by it. As a 
result of syphilitic infection in utero, the child may be 
born prematurely, and dead ; it may be born at term, 
dead, and showing specific lesions ; or it may be born 
alive with some syphilitic eruption ; or, as is com- 
monly the case, the eruption may not appear before the 



634 DISEASES OF THE SKIN. 

second or third week. Miller/ from a study of 1000 
cases of congenital syphilis in a foundling hospital in 
Moscow, found that the first appearance of the disease 
was in the first month of life in 64 per cent, of the cases ; 
and in the second month in 22 per cent. In congenital 
syphilis there is a marked absence of that sequence of 
events more or less observed in acquired syphilis, but the 
diagnosis is usually quite as easy. The earliest eruption 
to appear, as to point of time, is, according to Miller, the 
bullous syphilide, which he met with in 25 per cent, of 
the cases. One of the earliest and most characteristic 
symptoms of hereditarysy philis is " snuffles," due to an 
ozsena, which gives the child great discomfort by inter- 
fering with breathing and nursing. 

The erythematous syphilide is, according to Taylor, the 
most frequent and earliest eruption ; according to Miller, 
it occurs in 45 per cent, of the cases. It begins on 
the lower part of the abdomen as minute round or oval 
spots, that disappear under pressure at first. It invades 
the whole body within a week, when the lesions will no 
longer fade under pressure, but assume the characteristic 
syphilitic color. One form of the erythematous syphilide 
in children is seen upon the inside of the thighs, about 
the anus, and on the buttocks, and may extend down to 
the feet. It is patchy in character, the patches being 
either of small size, or large by the coalescence of several 
smaller ones. It differs from intertrigo in its patchy 
character, in its darker color, and in its wider distribu- 
tion. 

The papular syphilide and its modified forms of the 
mucous patch and condylomata lata are common congeni- 
tal lesions. The lenticular syphilide, large and small, is 
met with far more frequently than the miliary papular 
syphilide. It is usually a symmetrical and general erup- 
tion. It may be smooth or scaly, and always has the 
raw-ham color. Mucous patches are very often at the 
junction of the mucous membrane, and the skin, as on the 



SYPHILIS. 635 

lips or anal orifice. The movements of the parts will 
give rise to painful fissures — rhagades — which constitute 
a sign of hereditary syphilis as characteristic as the 
" snuffles." These rhagades Miller met with in 70 per 
cent, of his cases. Mucous patches also occur in the 
cavity of the mouth. Condylomata lata occur where two 
skin surfaces rub together, and especially where there is 
more or less moisture, as about the anus and genitals, in 
the groins and axillae, and between the fingers and toes. 
Their color is usually grayish pink to dark brown ; their 
size varies greatly, and their surface is flat, or fissured 
and ulcerated, and exudes an offensive secretion. They 
are characteristically located when at the angles of the 
mouth, iu combination with mucous patches in the mouth 
with rhagades between. 

The pustular syphilide may be general, but is usually 
most pronounced on the thighs, buttocks, and face. It 
shows a tendency to group about the mouth. It is usually 
indicative of profound syphilization. The pustules may 
leave scars. Ecthymatous pustules may develop, but 
usually not till late in the disease. 

The vesicular syphilide is a rare form of early congeni- 
tal syphilis of severe type. It is never general, but ap- 
pears as groups of closely packed together vesicles upon 
the chin, about the mouth, or on the nates, forearms, 
hypogastrium, or thighs. They are seated upon infil- 
trated, brownish-red bases. The larger vesicles may be 
seated upon papules. This eruption is apt to be asso- 
ciated with a pustular or bullous syphilide. 

The bullous syphilide, unlike what obtains in adults, is 
comparatively common in congenital infantile syphilis. 
Miller found it in 25 per cent, of his cases. It fre- 
quently exists at birth or as the earliest syphilide, and 
is indicative of a severe form. It is most commonly seen 
on the palms and soles, which are often covered with the 
lesions, while few, if any, are on the trunk. The face is 
a favorite location for the eruption. The bullae are either 
tense or flaccid, and at first have sero-purulent contents 



636 DISEASES OF THE SKIN. 

that soon become purulent. They are seated upon a raw- 
ham colored infiltrated base. Hemorrhage into them not 
infrequently occurs. When they rupture or dry up they 
exhibit an unhealthy-looking ulceration that soon be- 
comes covered with a greenish crust. Some of them may 
dry up with little, if any, ulceration. It rarely relapses. 
It differs from pemphigus in occurring upon the palms 
and soles, while sparing the trunk, and in the profound 
cachexia and the presence of other signs of syphilis. 

The tubercular syphilide is not common, and is always a 
late lesion. While it may be seen as early as the sixth 

Fig. 88. 




Hutchinson's teeth. 

month, it is more apt to occur much later as a relapsing 
syphilide. In appearance and course it resembles the 
same lesion of acquired syphilis. 

The gummatous syphilide is also a late manifestation of 
the disease, and is sometimes met with in early adult life 
as a lesion of congenital syphilis. 

Kaposi regards as a special and characteristic symptom 
of hereditary syphilis a diffused infiltration of the palms 
and soles, the skin of which is uniformly brownish red, 
dry. shiny, and fissured. 

Besides the skin-lesions the infant bears certain unmis- 



SYPHILIS. 637 

takable signs of syphilis. It has a marked pallor, and, 
no matter how blooming it may appear at first, it soon 
loses flesh and assumes " an old man " countenance. It 
has a characteristic, hoarse, toneless cry, which once heard 
will be remembered. Its hair is scanty, its nose is apt 
to be flattened, and altogether it is a most woebegone- 
looking object. The skin eruptions usually occur within 
the first six months of life, and if the child can be brought 
through that period it may suffer no more. Nevertheless, 
congenital syphilis, like the acquired disease, may be latent 
for years, to crop out once more. The victims of congen- 
ital syphilis, sometimes show the notched or peg-shaped 




Dactylitis. (After Bergh.) 

teeth, regarded by Hutchinson as a certain sign of the dis- 
ease (Fig. 88.) This appearance is presented by the 
second set of teeth only, and is not absolutely diagnostic, 
as the same has been met with in scrofula. The two mid- 
dle upper incisors are those which are depended on for 
diagnosis. " They are small, often converging, some- 
times diverging. The cutting-edge of the teeth is some- 
times narrowed, rounded off. They are stunted and badly 
developed, often marked with seams in front, and of a 
dirty-brownish color, but their chief peculiarity is found 
in their edges, which, being thin when cut, break off cen- 
trally, leaving a broad, shallow, vertical notch on the lower 
border of the tooth/ 7 (Keyes.) The syphilitic child is 
subject to diseases of the bones, one of the most charac- 
teristic of which is dactylitis. Another characteristic is 



638 DISEASES OF THE SKIN. 

the prominent bosses on the forehead. Space will not per- 
mit of a detailed description of the bone and other lesions 
apart from those of the skin. 

Treatment. The treatment of syphilis is by the use 
of both constitutional and local remedies, and by a con- 
stant and long-continued watchfulness on the part of the 
physician over the patient's hygiene and general well- 
being. One chief obstacle to the successful treatment of 
a case is the patient's lack of faith in his physician. Most 
patients, just as soon as the eruption for which they sought 
advice fades away, will cease coming to the physician, 
and will pay little heed to his warning, that unless they 
keep themselves under medical supervision for three or 
four years they will be liable to serious trouble later on. 
Nevertheless, our first duty is to so instruct them. Then, 
before putting the patient upon a regular course of treat- 
ment, we should give him careful directions as to his 
exercise, liberal diet, and bathing, and should stop his 
alcohol, insist upon his taking plenty of sleep, and giving 
up the use of tobacco. This last is not only to put him 
in better condition, but also to prevent mucous patches in 
the mouth. The patient should be cautioned against 
drinking out of public drinking-cups, and apprised of the 
danger of infecting others by means of table utensils, 
pipes and the like. Now he is ready for his course of 
treatment. 

Constitutional Treatment. The drugs employed and 
found of value in syphilis are chiefly but two, namely, 
mercury, and iodine in combination with sodium or potas- 
sium. These drugs are given in varying combination, 
and during varying periods, according to the views of 
different physicians. Mercury is the remedy relied on 
most for combating the disease, and should be used under 
ordinary circumstances by itself alone during the first 
year or two of the disease. The iodides exercise a marked 
control over the ulcerative syphilides, and the late or 
precocious manifestations of the disease. By some they 
are given continuously or as the sole remedy in late 



SYPHILIS. 639 

syphilis, but the best practice is in favor of their admin- 
istration either with mercury or instead of mercury for a 
short time. Treatment should be begun as soon as we 
are sure that the patient has syphilis. As an element of 
doubt may often enter into our diagnosis of the initial 
lesion, it is a good general rule not to administer specific 
treatment until the appearance of some secondary symp- 
tom. This plan has the additional advantage of producing 
a moral effect upon the patient, who, if he sees an erup- 
tion upon himself, will be more apt to believe that he has 
syphilis, and to submit himself to a thorough course of 
treatment. 

We will consider first the treatment of early syphilis 
and the use of mercury. This drug, regarded by the 
majority of physicians as the sheet-anchor in the treat- 
ment of syphilis, is administered, for its constitutional 
effect, by the mouth, by inunction, by fumigation and by 
hypodermic injection. 

Of these different methods, the most frequently em- 
ployed is the first — that is, by the mouth. The salt of 
mercury that I most frequently use is the protiodide, 
otherwise called the green iodide. This may be exhibited 
either in pill, tablet triturate, or granule ; and as the tab- 
let triturate is easily obtainable, very reliable, and quite 
inexpensive, my preference is for that preparation. Keyes 
prefers the granules of French manufacture, and says that 
the very objection raised by many authorities to the use 
of the protiodide, namely, its irritant effect on the intes- 
tinal tract, is its shining virtue, because instead of giving 
warning of intoxication by causing salivation, it does so 
by causing diarrhoea. The dose to begin with should be 
from \ to \ of a grain three times a day after meals, and the 
number of pills increased by one every third or fourth day 
until there is a little "colicky diarrhoea." The dosage 
should be then continued at the same number of pills, 
until the symptoms are controlled. Then we can reduce 
it to half the number. It may be necessary to give a 
little opium at the same time with the mercury, in order 



640 DISEASES OF THE SKIN, 

to control the diarrhoea if it is deemed advisable to con- 
tinue at the point of full tolerance, and this not only 
with the protiodide, but with other salts. Practically 
the daily dose of the protiodide may be put at 4 or 5 of 
the | grain tablets, and 3 or 4 of the J grain ones, and 
opium is rarely called for. 

Many prefer to use metallic mercury in the form of 
hydrargyrum cum creta, or calomel in the dose of 1 or 
2 grains two or three times a day after meals, increased 
every three or four days sufficiently to influence the erup- 
tion. Salivation is, in the general run of cases, to be 
avoided. Some authorities prefer to combine a tonic with 
the mercury. Taylor gives the following : 



K Hydrag. protiodid., gr. viij-x; 

Ferri et quininse citrate., ^iss; 6 

Ext. hyoscyami, gr. vj ; 

Ft. pil. No. xxx. 



R Hydrarg. tannici, 


gr. xv-xxx ; 


1-2 


Quin. sulphat., 


3j ; 


4 


Ext. hyoscyami, 


gr. vj ; 




Ft. pil. No. xxx. 







52-65 
39 M. 

39 M. 



In severe cases in which it is necessary to get the 
patient rapidly under the influence of mercury, calomel 
in T \ grain doses in the form of tablet triturates may 
be given every hour until the gams become tender. 
Then the calomel should be stopped and the treatment 
continued with small doses of the protiodide. 

Besides these preparations of mercury we may use the 
bichloride in doses of ^ Y to y 1 ^ of a grain in solution. It 
is usually given in compound syrup of sarsaparilla or some 
bitter infusion. The most common mode of administer- 
ing it is in combination with the iodide of potassium, the 
so-called mixed treatment, the formula for which will be 
given later when speaking of the treatment of late 
syphilis. The best opinion is in favor of reserving the 
use of iodine until the early stage is passed. The tan- 
nate of mercury is well spoken of in the dose of half a 



SYPHILIS. 641 

grain. Space will not allow of mentioning the other salts 
of mercury that have been recommended. 

The proper quantity for administration having been 
learned by experiment, the drug should be administered 
continuously for from four to six months. 

Where practicable the use of mercury by inunction is 
the speediest and best way of getting the patient under 
the influence of the drug. It may be used from the first 
or at any time during the course of the disease. Its great 
advantages are the promptness with which it acts and the 
sparing of the stomach and intestinal tract. Its great 
disadvantages are that it is a dirty method, impracticable 
with most patients, as it attracts notice from his friends 
and attendants ; and the difficulty encountered in getting 
the patient to carry out the treatment with thoroughness. 
It is admirable for hospital treatment. The patient is to 
be told to rub into his skin, once a day, a piece of ungt. 
hydrarg. cinereum, or an ointment made with lanolin as a 
base, of the size of a hazelnut — from J a drachm to 1 
drachm. He is to divide the mass into two equal parts, 
and work it in with the heel of his hand for about fifteen 
minutes while he sits before a fire or in a warm room. 
Before beginning the inunctions he is to take a warm 
bath, and to bathe the parts about to be rubbed with 
alcohol so as to open the pores of the skin and to remove 
any sebaceous matter. The first day he is to rub the 
ointment into the bends of both elbows ; the second day, 
over the sides of the chest ; the third day, over the abdo- 
men ; the fourth day, on the inside of the thighs ; and the 
fifth day, behind the knees — that is, he is to choose the 
parts least covered with hair; and to change the sites of 
the inunctions, so as to avoid setting up a mercurial ec- 
zema. On the sixth day he is take another bath, and on 
the seventh day to resume the inunctions. The treatment 
is to be pursued until active symptoms of the disease are 
overcome, when all treatment may be suspended. A 
thorough course of from eighty to a hundred inunctions 
is said to be often followed by a permanent cure. If the 
41 



642 DISEASES OF THE SKIN. 

inunctions are to be made by an attendant, he should 
wear a stout rubber glove. As a substitute for in- 
unctions, E. Welander 1 proposes spreading about 1J 
drachms of mercurial ointment on the inside of a small pil- 
low tick, and having the patient wear this, properly 
fastened, next the skin over the anterior plane of the 
body, day and night. Mercuriol may be substituted for 
the usual mercurial ointment. These plans of treatment 
are good only in slight cases. 

Fumigation is a method which is not used as much now 
as formerly. It requires the use of a special apparatus and 
a great amount of time and trouble. It is said to be a very 
efficient method, specially useful in bad cases and where 
prompt results must be attained. From J to 1 drachm 
of calomel, metallic mercury, or other salt of mercury, 
is vaporized by meaos of the special apparatus, the 
naked patient sitting over it enclosed in a cabinet or 
blankets, out of which only his head protrudes. Each 
bath lasts ten minutes, and it is repeated every second day. 

The intramuscular injection method of administering 
mercury, was first advocated by Scarenzio in 1854 and of 
late years has been much experimented with. The injec- 
tions are usually made deep down in the gluteal region, 
behind and above the great trochanter. They are usually 
painful ; sometimes are followed by emboli and abscesses ; 
require daily or frequent visits to the physician's office; 
and do not seem to be followed by sufficiently lasting 
effects to warrant their routine employment. They are use- 
ful where we wish to have a very prompt effect from the 
mercury, as in a malignant precocious case of syphilis ; 
or where the stomach must be spared ; or where the dis- 
ease has not yielded to the ordinary plans of treatment. 
Great care must be given to the sterilization of the needle 
and of the skin. A great number of salts of mercury and 
combinations have been introduced, each one of which has 
been found by its producer the best and most reliable. 
An admirable study of them will be found in Hare's Sys- 
i Arch. f. Dermat. u. Syph., 1897, xl., 257. 



SYPHILIS. 643 

tern of Therapeutics, vol. ii., by Prof. R. W. Taylor. Here 
we can indicate, and briefly, but a few. Taylor gives one 
of corrosive sublimate, gr. xl; glycerin, 5j ; distilled water, 
Siij. of which 12 drops are used at each injection. The 
albuminate of mercury, dose 1 5 minims : the formamide 
(Liebreich), dose J to a whole Pravaz syringeful of a 1 
per cent, solution : calomel, 1 part, to liquid vaseline, 
12 parts, dose J Pravaz syringeful once a week; "gray 
oil," composed of 20 parts of pure mercury, 40 of liquid 
vaseline, and 5 of ethereal tincture of benzoin, dose J of 
a syringeful every ninth day; 1 the salicylate, 22 J grains 
in lanolin 15 grains and benzoinal ad §ss. Dose J to 1 
syringeful ; and many others. As a rule the soluble salts 
solutions are injected once every day or so, and the insol- 
uble ones once a week. A final judgment as to the com- 
parative merits of the many salts cannot yet be given, but 
the best opinion seems to be that the soluble salts of mer- 
cury are to be preferred. 

Late Syphilis.. If a patient who has not been under 
systematic treatment comes to us with a late syphilide, 
the so-called mixed treatment will be most appropriate to 
his case. As usually administered it is made up accord- 
ing to one of the following formulas : 



K Hydrarg. bichlor. vel., l gr j_y 



} 



Hydrarg. biniodidi 

Potass, iodidi, 3j-ij > 4-8 

Inf. gentian, co. vel, j ad ^ iy; ad m 



06-12 



M. 



Syr. sarsaparillse co., 
Dose : A teaspoonful three times a day after meals. 



Or 



? 

}£ Hydrarg. biniodidi, fgr. ss-ij ; 

Ammon. iodidi. gss ; 2 

Potass, iodidi, 3u'-^ j 8-32 

Syr. aurant. cort., ^jss ; 45 

Tr. aurant. cort., gj 5 4 

Aquae, q. s. ad ^iij ; ad 100 



08-12 



M. 



Dose : A teaspoonful in water, three times a day. (Keyes. ) 

* Leloir and Tavernier : Giorn. Ital. d, Mai, Ven. e del Pelle, 1889, 
xxiv., 247. 



644 DISEASES OF THE SKIK 

If a patient comes to us with a gumma, an ulcerative 
syphilide, a group of serpiginous tubercular syphilides of 
the tertiary period ; or if any of these or other deep 
lesions threatening destruction of tissue appear early in a 
case of precocious or malignant syphilis ; or if the dis- 
ease attacks the nervous system, the larynx, pharynx, or 
eye — in fact, at any time when there is need of prompt 
effects, we must administer the iodides. If he has had 
no mercury for some time, it is best to give it to him 
now either by the mouth, injections, or inunctions, while 
the iodide is administered separately but at the same time. 
The iodide of potassium is most generally used, and next 
to it the iodide of sodium. There is no set dose for the 
iodide. It is best given in a dose of 5 grains in solution 
in water, three times a day, before meals, diluted in milk, 
or Vichy, or soda-water ; or some three hours after meals. 
Delavan x has found that the iodide can be given most satis- 
factorily by putting 5 drops of a saturated solution in the 
bottom of a small tumbler, with 15 drops of essence of pep- 
sin, and pouring upon it 2 ounces of warm milk. This is to 
be set away in a cool place, and will form a rennet cus- 
tard, which can be easily swallowed. This is a good 
method when we wish to give nourishment with the 
medicine or when the throat is sore. The mixture can 
be given a pleasant taste by adding a teaspoonful of 
sherry wine. 

The dose of the iodide should be increased by 1 or 2 
drops each day — that is, 6 drops t. i. d. ; then 7 drops 
t. i. d., and so on, until the nose runs and the eyes water, 
or some symptom of iodism develops. The most con- 
venient method of administration is to have a solution 
made containing 1 grain of the iodide to each drop of 
the solution, so that every drop represents a grain. Most 
patients bear iodine well, but in some even drop doses 
produce iodism. Iodic acne is very often induced, but 
should not cause us to stop using the drug. It is advis- 
able to suspend the administration of the iodides from 
i Med. Rec, 1891, xl., 651. 



SYPHILIS. 645 

time to time, and to give mercury, which, after all, must 
be depended on for curing syphilis. 

Now and again we will meet with cases that do not 
improve under either mercury or iodine, but relapse and 
relapse, or remain stationary. Such cases should be sent 
out of town, ordered change of air for a time, and put on 
a purely tonic course of treatment. Very often when 
the patient returns home he can take his medication 
easily, and the previously obstinate lesions will yield 
readily. This is but what we said at first ; the patient's 
general condition must all the time be carefully watched 
over. 

Salivation is an unpleasant accident that may occur 
under the use of either mercury or iodine. At one time 
it was quite common — indeed, mercury was purposely 
pushed so far as " to touch the gums," and, of course, this 
was often overdone. Its symptoms are tenderness of the 
teeth, so that pain is felt when the jaws are snapped to- 
gether ; the gums are swollen ; there is a metallic taste 
in the mouth ; a fetid odor of the breath ; increased 
flow of saliva by day and night ; all the mucous mem- 
branes of the mouth are swollen, so much so as to inter- 
fere with mastication and deglutition, and in very bad 
cases there may be ulceration, loosening and fall of the 
teeth, and caries of the bones. 

Prevention is always better than cure, and to this end 
we should see that our patient's teeth are in good order 
before beginning treatment, and direct him to wash his 
mouth frequently with chlorate of potash solution, 10 or 
15 grains to the ounce, or one of alum, and to keep his 
teeth clean. The patient should be seen frequently at 
first, so as to stop the mercury before salivation attains 
any serious degree. Salivation having begun, the mer- 
cury must be stopped, and the potash solution in same 
strength may be continued, and 1 or 2 drachms of it 
swallowed during the day. The compressed tablets are 
useful. Dilute Labarraque's solution, or solutions of per- 
manganate of potash or other astringent, may be used for 



646 DISEASES OF THE SKIN. 

a gargle and mouth-wash. A laxative should be admin- 
istered, the patient kept warm in bed, and, if necessary, 
an anodyne given. 

Duration of mercurial treatment. How long the patient 
should take mercury is a question, the answer to which is 
very variously given by different authorities. Keyes puts 
it at from eighteen months to four years. Taylor says " at 
least two years to two years and a half, counting from the 
date of the commencement," but he advocates intermis- 
sions of from two to three months, iodide of potassium 
being given in the meantime. Schwimmer 1 advocates 
giving mercury for two or three months, and then one of 
the iodides for two months ; after four or five months of 
treatment making a pause of two or three months, treat- 
ing any local lesion locally, and then repeating the course. 
Fournier 2 usually administers mercury for six to nine 
weeks ; then pauses six weeks ; then gives another six 
weeks' medication. During the first year he puts the 
patient through four courses ; during the second year, 
three courses; and during the third year, two courses. 
During the fourth year he gives the iodide alone for six 
weeks, with corresponding intervals. Crocker advises 
stopping mercury about every six weeks to give the iodide 
for a week or ten days. At the end of six months, if the 
patient has been free from symptoms for two or three 
months, a month's pause may be made, to be followed by 
a six weeks' course of mercury. And so through the first 
year. During the second year he alternates a six weeks' 
mild mercurial course with a one or two weeks' course of 
the iodide. If still free from lesions, treatment may be 
suspended until some symptom appears. 

Against these advocates of long-continued mercurial 
treatment there are others, no less eminent, who advocate 
the administration of mercury only during the duration of 
the symptoms, and for a few months afterward ; then they 
advise to suspend all treatment until some new outbreak 

1 Second Supplement to the Monatshefte f. prakt. Dermat., 1888. 
2 Gaz. des Hop., 1889, No. 103. 



SYPHILIS. 647 

of the disease calls for it. In combating so insidious a 
disease as syphilis, it seems to me wise to err rather on 
the side of too long continued treatment than on that of 
a too short course. 

Local Treatment. While internal treatment by 
mercury and the iodides is quite competent to remove the 
syphilodermata, their disappearance can be materially 
hastened by local treatment by means of mercurial 
applications. Ointments of metallic mercury, of the 
ammoniate, the red oxide, and the oleate, with solutions 
of the bichlorides, are the preparations most generally 
employed. 

Many attempts have been made to abort syphilis by 
excision of the initial lesion, or its destruction by means 
of caustics. These have been failures in most instances. 
This is not to be wondered at in the light of R. W. 
Taylor's studies, 1 which show that " in the very first 
days of syphilitic infection the poison is deeply rooted 
beneath the initial lesion, and extends far beyond it, 
infecting all the parts beyond, even to the root of the 
penis." The initial lesion should be dressed with iodoform 
or calomel, or kept covered with dry lint powdered with 
either of these. 

It may be said that in all the early and generalized 
syphilides local treatment needs practically to be applied 
only to lesions on exposed parts — that is, face, neck, hands, 
and wrists. The erythematous syphilide is usually so 
ephemeral that no local treatment is necessary. Mer- 
curial baths may, however, be used for general outbreaks 
of syphilis. If the erythematous lesions persist upon the 
exposed parts, their departure can be hastened by the use 
of the ointment of the ammoniate of mercury rubbed in 
morning and night. The same ointment may be applied 
to the papular syphilide. A still more prompt effect can 
be produced, if the patient can be seen often enough, by 
the physician touching each lesion with a solution of the 
bichloride of mercury in alcohol 3 to 5 grains to the 
iMed. Rec, 1881, xl., 1. 



648 DISEASES OF THE SKIN. 

ounce, according to the size of the lesions and the profuse- 
ness of the eruption. Of course, if the eruption is very 
profuse, this plan cannot be followed. It is most appli- 
cable to a sparse and relapsing eruption. The mucous 
patch should be touched with the nitrate of silver stick or 
with an aqueous solution of chromic acid, 10 grains to 
the ounce. Condylomata are best treated with dusting 
powders, preferably calomel, freely applied and covered 
with absorbent cotton. 

The squamous syphilide of the palms and soles is often 
obstinate, but will usually yield to the persistent use of 
mercurial ointment. Sometimes it will be necessary to 
soften the part by having the patient wear sheet rubber 
next the skin for several days, and then use the ointment. 
If the parts are covered with a very much thickened epi- 
dermis, we may have to remove this by using salicylic acid, 
as in chronic squamous eczema. Mercurial plaster worn 
continuously is efficient. 

The tubercular syphilide occurring discretely can be 
touched with the bichloride solution already mentioned. 
When in groups it is best treated by means of mercurial 
plaster. 

The gumma may be covered with mercurial plaster or 
ointment. It should not be incised unless it shows unmis- 
takable evidences of containing pus. 

Ulcers following whatever lesion may be covered with 
mercurial plaster or ointment, or dressed with iodoform 
or aristol. If they become sluggish, they may require 
stimulation, just as a simple ulcer does. To this end we 
may touch them with balsam of Peru, or add the same to 
our mercurial ointment. Some ulcers will do best under 
the treatment applicable to a simple ulcer, while the iodide 
of potassium is pushed. 

Treatment of Congenital Infantile Syphilis. 
The most popular method is to spread upon pieces of 
flannel a mass of mercurial ointment of about the size of 
the end of the finger, and tie a piece of this one day over 
each elbow-joint ; another day over each groin ; another, 



SYPHILIS. 649 

under each knee ; and another, over the abdomen, allowing 
the movements of the child to work the ointment into the 
skin. Or hydrarg. cum creta, 1 grain three times a day, 
may be given by the mouth. Monti 1 recommends the 
following : 



R Calomel, pur., 


gr. iss; 


il 


Ferri lactatis, 


gr. iij ; 


2 


Sacch. alb., 


gr. xlv: 


3\ M. 


Ft. in pulv. No. x. 






Big. 1 to 4 powders daily. 







The greatest attention must be given to the hygiene of 
the child and to its diet. Cod-liver oil should be given 
along with the mercurial. The nose must be kept clear, 
and if this is not practicable the child must be fed with 
spoon. After the disappearance of symptoms tonics should 
be given, one of the best being the syrup of the iodide of 
iron. In all other respects the treatment of infantile 
syphilis is the same as that of the acquired form. Kaposi 
commends the tannate of mercury for children ; dose, J 
to f of a grain three times a day. 

Prognosis. The prognosis of syphilis as seen at the 
present time and in this country may be said to be good. 
Many cases go no further than a general erythematous or 
papular eruption, even when untreated. In one of robust 
health the disease is usually readily manageable. In 
debilitated subjects it sometimes proves intractable. The 
worst feature of the disease is the great uncertainty of its 
course, no one being able to promise confidently, no 
matter with what treatment, that relapses and late visceral 
syphilis will not occur. Therefore, the prognosis should 
be guarded, while it is remembered that rare cases of 
secondary infection attest the possibility of complete 
recovery. 

The prognosis of congenital syphilis is not as good as 
is that of the disease as it affects adults. Many, perhaps 
most, of the cases seen in public institutions die. In pri- 

1 Arch. f. Kinderheilkunde, 1885, vi. } 1. 



650 DISEASES OF THE SKIN. 

vate practice more can be done, and we should always 
count upon the remarkable reparative powers of childhood 
in making our prognosis. A great deal will depend upon 
the inborn vigor of the child. 

Syringomyelia, or Morvan's Disease, is a disease of the 
spinal cord, the consideration of which belongs rather to 
the neurologist than the dermatologist. It interests us 
because various cutaneous lesions occur during its course, 
such as glossy skin, hyperkeratosis, hyperidrosis, and 
paronychia with necrosis of the phalanges ; and because 
in some phases it resembles certain stages of leprosy. 

Syringo-cystadenoma. See Epithelioma, multiple, be- 
nign, cystic. 

Tache Atrophique. See Atrophoderma. 

Tache Bleue. See Pediculosis. 

Tache Cafe-au-lait, seu Congenitale, seu de Feu, seu 
hemorrhagictue, seu Pigmentaire, seu Vasculaire, seu Vine- 
use. See Nsevus. 

Tache Hepatique. See Chloasma. 

Tache Ombrees. See Pediculosis. 

Tan. See Lentigo. 

Tanne. See Acne. 

Tattoo. These well-known stainings of the skin by 
means of India-ink, vermilion, charcoal, and gunpowder, 
although at first objects of pride to the boy or girl, later 
are apt to become objects of aversion. They are very 

Fig. 90. 



•J4 OF REAL SIZE. 

Keyes's punch. 

difficult to remove, especially if they are at all extensive. 
Patient perseverance in going over and over the small 
ones, that cannot be excised, with the electrolytic needle 
will sometimes greatly lessen them, though, of course, we 
thereby substitute a white cicatricial spot for a colored 



TEIGNE GEANULEE. 651 

one. The needle should be introduced perpendicularly to 
the skin and deeply, and numerous punctures arranged 
in rows thus made. This, of course, is a very slow pro- 
cedure, Powder-grains may be removed by Keyes's 
punch, by making a half-turn over them, and then 
snipping off the small piece with the scissors. (Fig. 93.) 
Ohmann-Dumesnil 1 recommends thrusting into the 
stain a bunch of 6 to 10 very fine cambric needles, tied 
tightly together with silk thread, after dipping them into 
the glycerole of papoid. This is composed of: 



R Papoid, gr. ij ; 

Aquae destil., 5j j 4 

Glycerin, pur. , ,5iij ; 12 

Ac. hydrochlor. dil., gtt. iij ; gtt. iij 



13 



M. 



If required, anaesthesia may be obtained by the ethyl 
chloride spray. The needles are to go deep enough to 
bring a few drops of blood to the surface. After punc- 
turing, pour over the surface some of the solution and 
cover with antiseptic gauze. Remove this after two or 
three days. In this way the whole tattoo-mark is to be 
gone over. It may have to be gone over a second time. 
J. Brault 2 recommends tattooing the marks with a 
solution of 30 parts of chloride of zinc and 40 parts of 
sterilized water. The superficial eschar falls in five or 
ten days. The process may have to be repeated several 
times. Variot 3 first covers the part with a concentrated 
solution of tannin which he tattoos into the skin, the 
punctures being made close together. Then he passes a 
stick of nitrate of silver over the part, allows it to re- 
main for a few minutes, and then washes it oif. A 
black crust forms that falls in a few weeks leaving a 
scarcely perceptible scar. 

Teigne Faveuse. See Favus. 
Teigne Granulee. See Pediculosis. 

1 New York Med. Journ., 1893, lvii., 544. 

2 Ann. de derm, et de syph., 1895, vi., 33. 

3 Compt.-Rend. Soc. Biol., 1888, p. 636. 



652 DISEASES OF THE SKIN. 

Teigne Imbriquee. See Trichophytosis corporis. 
Teigne Pelade. See Alopecia areata. 
Teigne Tondante seu Tonsurante. See Trichophytosis 
capitis. 

Telangiectasis, This is an acquired dilatation ot the 
bloodvessels. The condition is well seen in rosacea. 
But it seems to me best to reserve the term for those 
cutaneous lesions in which acquired dilatation of the 
bloodvessels of the skin is the only condition present. 

Symptoms. The most common form of the disease is 
ncevus araneus, or what is vulgarly called " spider can- 
cer" It occurs in nearly all cases upon the cheeks, near 
the eyelids or bridge of the nose, but may occur any- 
where. It is usually a single lesion, and consists in a 
small, central, bright-red, slightly raised dot from which 
radiate fine red lines. They sometimes become quite 
large, though usually not more than a half-inch in dia- 
meter. This form is seen in women and children. It 
occasionally follows some slight injury, but very often 
seems to come spontaneously. 

Telangiectases in the form of simple dilated blood- 
vessels of varying size and shape are often seen. Under 
the same heading Crocker places those slightly convex or 
flat, hemp-seed-sized, raised, bright-crimson or purplish 
spots met with in old people. Their favorite site is the 
upper part of the trunk, neck, and face. 

Etiology. Telangiectases sometimes are the result of 
some slight injury, as the prick of a pin or a mosquito- 
bite. Sometimes they are due to continued congestion 
of the skin from disease of the internal organs. In 
other cases they result from a chronic inflammatory dis- 
ease of the skin. They are very common upon the 
trunk in advanced life. 

Treatment. The treatment of telangiectasis is sim- 
ple. It is only necessary to introduce the electrolytic 
needle into the red central spot, and turn on a current of 
about 2 milliamperes. The mode of operating is similar 



TRICHIASIS. 653 

to that used in destroying superfluous hair, and is de- 
scribed in the section on Hypertrichosis. It may be 
destroyed by touching it with a drop of nitric acid, or 
puncturing it with a white-hot-needle. 

Tetter. See Eczema. 

Tinea Amiantacea, seu Asbestina, seu Furfuracea. See 
Seborrhoea. 

Tinea Circinata, seu Cruris, seu Imbricata. See Tricho- 
phytosis corporis. 

Tinea Decalvans. See Alopecia areata. 

Tinea Favosa. See Favus. 

Tinea Kerion. See Trichophytosis capitis. 

Tinea Nodosa, This is a condition of incrustation of 
the hairs with a fungous growth forming dry, hard, 
elongated, formless masses varying in color from olive to 
brownish yellow, giving a rough feel to the hair. The 
hair follicles are unaffected, and the hair is firmly seated 
in them. The hair may be simply incrusted or it may 
be split. The free end of the hair is more affected than 
the proximal end. The spores composing the incrusta- 
tions are similar to the trichophyton, but smaller. It is 
seen specially on the hairs of the beard and mustache. 
It differs from piedra in not affecting the scalp hair and 
in its fungus. The best treatment is to shave the hair 
off. If this is objected to it may be removed by the fre- 
quent application of sweet oil with 2 per cent, of salicy- 
lic acid. 

Tinea Sycosis. See Trichophytosis barbae. 
Tinea Tondens seu Tonsurans. See Trichophytosis 
capitis. 

Tinea Trichophytina. See Trichophytosis. 
Tinea Versicolor. See Chromophytosis. 
Trichauxis. See Hypertrichosis. 

Trichiasis. This is a congenital or acquired displace- 
ment of the cilise so that they point backward and 



654 DISEASES OF THE SKIN. 

scratch the cornea. Both lids of both eyes are usually 
affected. 

The best treatment is the destruction of the hair by 
means of the electrolytic needle, as described in the sec- 
tion upon Hypertrichosis. 

Trichoclasia. See Trichorrhexis nodosa. 
Trichoptylose. See Trichorrhexis nodosa. 
Trichomycose Noueuse. See Piedra. 
Trichomycosis Nodosa. See Leptothrix. 
Trichomycosis Palmellina, See Tinea nodosa. 
Trichonodosis. See Nodulus laqueatus. 
Trichinosis Cana vel Discolor. See Canities. 
Trichonosis Furfuracea. See Trichophytosis capitis. 
Trichophytie Circinee. See Trichophytosis corporis. 
Trichophytie Sycosique. See Trichophytosis barbae. 

Trichophytosis. A contagious disease of the skin and 
hair, occurring most often in children, due to the invasion 
of the epidermis by the trichophyton fungus, and charac- 
terized by the formation of circular or annular scaly 
patches, and partial loss of hair. 

As its name indicates, this is a disease produced by the 
trichophyton fungus. It may find lodgement and grow 
on the general cutaneous surface, in the scalp, beard, or 
nails — that is, in the epidermic structures. In these dif- 
ferent localities it develops so differently as to produce 
very different clinical pictures. I shall describe each one 
by itself and give its differential diagnosis, treating all 
matters of etiology and treatment collectively. 

Trichophytosis Corporis. Synonyms : Tinea circinata ; 
Herpes circinatus ; (Fr.) Herpes circiue, Trichophytie cir- 
cinee ; (Ger.) Scheerende Flechtc; Ringworm of the body. 

Symptoms. This is the simplest and most readily 
cured of all the forms of ringworm. It begins as a small, 
pale red, slightly raised spot, which, growing, spreads out 
into a round, sharply defined, scaly patch ; then it clears 
up in the middle, becomes ring shaped, and advances 



TRICHOPHYTOSIS CORPORIS. 



655 



with a raised border that may be vesicular ; or crusted 
from the drying of the vesicular contents ; or papular and 
scaly. After a time it either ceases to spread, or, enlarg- 
ing, the edge of the ring becomes broken in places. At 
last it undergoes spontaneous involution. There may be 
but a single patch or there may be a number of patches. 
If two circles meet at their peripheries, they coalesce and 



Fig 




Trichophytosis corporis. (By the courtesy of Dr. S. Dana Hubbard ) 

form gyrate figures. Very often rings do not form, and 
we have only a round, sharply defined, scaly, circular 
patch. The exposed parts — face, hands, and neck — are 
the most common sites for the eruption. In rare cases 
ringworm may be widely disseminated over the body. A 
slight amount of itching is the only subjective symptom, 
and that may be wanting. 

Another form of ringworm of the body is that known 



656 DISEASES OF THE SKIN. 

as eczema marginatum, which is ringworm located in 
the crotch or axilla. It is usually of a more highly 
inflammatory character than the same disease on other 
parts of the body, and resembles an eczema very closely — 
in fact, it is often complicated by an eczema. The edge 
of the patch is sharply defined, raised, scalloped, papular, 
and scaly, while the centre may be smooth or pigmented 
and crusted. The patch often attains large dimensions, 
running down the inside of the thigh, up over the abdo- 
men, and backward over the perineum. Usually the 
inside of both thighs is affected. There is considerable 
itching. The same symptoms are presented when the 
axillae are affected. There is also a true eczema of the 
crotch to which the same name has been given, that is 
not due to the trichophyton, but resembles the form just 
described. 

Tinea imbricata is supposed to be a very aggravated 
form of body ringworm occurring in tropical countries. 
But Manson 1 says that it differs from ordinary ringworm 
in affecting a very large part of the body at the same 
time ; in avoiding hairy parts and sparing the hair ; in 
an absence of signs of inflammation ; in not forming a 
single ring, but ring within ring, and recurring in parts 
already affected ; in having large, abundant scales ; in 
profuse fungous growth ; in always breeding true in in- 
oculation-experiments ; and in occurring only in certain 
parts of the world. It begins as a brownish macule or 
papule which enlarges to form a scaly ring. The fully 
formed lesion is a series of concentric rings, the outer one 
being about T \ inch wide, brownish-red, and apparently 
just under the epidermis ; inside of this is a red, raised, 
scaly ring ; inside of that a pale shiny ring ; and at the 
centre a brown, slightly raised spot J- inch in diameter. 
There may be eight or more concentric rings. There 
may be many lesions, and later the rings may disappear 
and the whole body may be covered with pityriasic 

1 Brit. Journ. Dermat., 1892, iv., 5. 



TRICHOPHYTOSIS CAPITIS. 657 

scales. The disease itches. It attacks people of any age 
and either sex. 

Diagnosis. Trichophytosis corporis is readily diag- 
nosed, as its appearance is distinctive. Favus of the body 
may spread out into a circular patch, but soon it will show 
the distinctive sulphur-yellow cupped crusts. Psoriasis 
on the body will have a brighter red color ; its scales will 
be more abundant, thicker, and brighter ; it will be found 
on the tips of the elbows and over the knees, and will be 
more profuse and disseminated ; and examination of the 
scales will show an absence of fungus. The scaling pap- 
ular syphilide or the squamous syphilide will not itch ; 
there will be no fungus in the scales ; the color will be 
that of raw ham ; the base will be more infiltrated ; it 
will run a more chronic course ; and will not yield so 
readily to treatment. Seborrhea of the chest may occur 
in rings, but its location will suggest its origin ; the skin 
is greasy, the scales rub off easily, and there is no fungus 
in them. Eczema of the crotch or axilla differs from 
ringworm of the same region in not having a so sharply 
defined and scalloped or festooned border ; in forming a 
more evenly diseased patch with no sound skin in it ; and 
in having no fungus in the scales taken from it. Pity- 
riasis rosea is more widely distributed than is ringworm, 
and spreads more rapidly ; it is not so scaly ; has a more 
yellowish centre ; is usually more abundant on the trunk ; 
shows no fungus under the microscope ; and the eruption 
is made up of both macules and rings. 

Trichophytosis Capitis. Synonyms ; l Herpes tonsurans 
seu circinatus, seu squamosus ; Tinea tonsurans, seu ton- 
dens ; Porrigo furfurans ; Dermatomykosis tonsurans 
(Kobner) ; (Fr.) Herpes tonsurante, Teigne tondante ou 
tonsurante, L/herpes circine" parasitaire ; (Ger.) Scheerende 
Flechte ; (Slav.) Ringskurv ; Ringworm of the scalp. 

Symptoms. This form of ringworm is seen almost ex- 

1 1 can mention here only the more common ones, as their number 
is legion. 

42 



658 



DISEASES OF THE SKIN. 



clusively in infants and children. As puberty or early 
adult life is reached the disease, no matter how long con- 
tinued, and how severe it may be, tends to get well of 
itself. It begins as a single vesicle or a small, insignifi- 
cant, red, scaly spot that would pass without suspicion 
of its nature unless other cases of ringworm put us on our 

Fig. 92. 




Trichophytosis capitis.! (Fox.) 



guard. From this small beginning the disease spreads 
peripherally to form a circular patch, which is covered 
with grayish scales, sharply defined, perhaps slightly ele- 
vated, and partially bald, and slightly if at all red ; or 
the patch may be a little elevated, reddened, and crusted 
looking like a patch of eczema. Inspection of the patch 

i G. H. Fox ; Skin Diseases of Children. Wood, N. Y., 1897, 



TRICHOPHYTOSIS CAPITIS. 659 

will show a number of broken-off stumps of hairs with 
split ends. These stumps are characteristic of the dis- 
ease. The hair growing in and about the patch is dry, 
lusterless, split, and brittle. Attempts at epilation break 
it off, and if it is indented with the finger-nail it will take 
a sharp angle and retain it. This shows that it has 
lost its resiliency. Apparently healthy hairs are some- 
times growing from the patch. The size of the patch 
varies greatly. It may be no larger than that of a ten- 
cent piece, or it may be so large as to denude a good part 
of the scalp. These large patches are usually formed by 
the coalescence of several small ones, and then they lose 
their circular outline and become scalloped. There may 
be but a single patch, or there may be a number of them. 
After attaining the size of a half-inch to one inch in dia- 
meter the patches may remain stationary in size or in- 
crease slowly. The most frequent sites are the vertex 
and parietal regions. Pruritus of greater or less degree 
is usually complained of, and it may be the first symptom 
that draws attention to the child's scalp. The course of 
the disease is exceedingly chronic. It does not produce 
permanent baldness. 

This is the typical " ringworm," as seen in the vast 
majority of cases. Sometimes, instead of being scarcely 
or not at all raised above the surface of the skin, the 
patch usually a single one, begins to swell up, becomes 
raised, uneven, and boggy, and we have the condition 
described as kerion (which see). The granuloma tricho- 
phyticum of Majocchi is simply a form of kerion. An- 
other variety is what Liveing terms bald tinea tonsurans. 
This begins as an ordinary ringworm, but after a time 
the hair all falls out, the scalp is smooth and without 
scales, as in alopecia areata, and at its border there may 
be found short broken hairs, like those seen in the latter 
disease. At first this change takes place in one patch 
alone, and we will be guided to a right diagnosis of the 
disease by the appearance of the other patches. Later, 
these too become altered, and then it would be hard to 



660 DISEASES OF THE SKIN. 

make the diagnosis without the history of there having 
been scaly patches. This is an infrequent form of the 
disease. 

Still another form is called disseminated ringworm. 
Here the patchy character of the disease has disappeared, 
the hair has apparently grown in nicely, and there is seem- 
ingly only a scurvy condition of the scalp. This is a dan- 
gerous form, because the child is often regarded as well and 
yet is quite capable of spreading infection. Careful exami- 
nation of the case, by causing the child to stand with his 
back to the physician, and turning the hair slowly back- 
ward against its direction of growth, will show here and 
there "stumps," and also the presence of hairs that stand 
up from the head for a few moments. Normal hair falls 
quickly back into place, which is not the case with hair 
affected with ringworm. 

A pustular form is sometimes described. It is simply 
a ringworm occurring in a strumous subject, in whom all 
inflammatory skin diseases are prone to assume a pustular 
character. 

Diagnosis. Trichophytosis capitis must be differenti- 
ated from alopecia areata, favus, eczema, seborrhoea, and 
psoriasis. From alopecia areata it differs in being scaly ; 
in not producing perfectly bald patches ; in its much slower 
progress ; in the presence of " stumps ;" and in having the 
trichophyton fungus in the hair, as seen under the micro- 
scope. From favus it differs in the absence of the sulphur- 
yellow cupped crusts of that disease ; in not having such 
heaped-up asbestos-like crusts; in forming distinct round 
patches ; in the more brittle character of its hair ; in not 
producing red, smooth, permanently bald spots that later 
become white and cicatricial, and in showing a marked 
tendency to get well of itself as puberty is reached. The 
diagnosis between them by the microscope is not easy 
without a knowledge of the appearance on the skin. The 
spores of favus are more polymorphous and somewhat 
larger than those of trichophytosis, and its mycelia are 
more abundant than its spores. From eczema it differs 



TRICHOPHYTOSIS BARBJS. 



661 



in the more circumscribed and circular character of its 
patches ; in being less itchy ; and in the presence of broken- 
oif hairs and stumps. The presence of these broken-off 
hairs and stumps, and of the fungus in the hair and scales, 
will sufficiently distinguish ringworm from both seborrhoea 
and psoriasis. 

Trichophytosis Barbae. Synonyms : Tinea sycosis, seu 
barbae ; Sycosis parasitaria seu parasitica ; Herpes ton- 

Fig. 93. 




Trichophytosis barbae. 
(From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 

surans barbae (Fr.) Trichophytie sycosique, Sycosis 
parasitaire ; (Ger.) Parasitische Bartfinne ; (It.) Sicosi 
parasitaria ; (Eng.) Barber's itch, Ringworm of the beard. 
AVhen the trichophyton invades the beard, it may take 
the form of a superficial scaly circular patch which in- 



662 DISEASES OF THE SKTN. 

creases in size, just as on the scalp, producing broken-off 
hairs and a partially bald area. There may be several 
of these areas upon the chin and cheeks. Or it may take 
the more usual form in which there will be either some 
pustules pierced . by hairs, or else a group of large 
nodular swellings, varying in size from that of a split pea 
to that of a half-cherry, arranged in the form of a circle. 
There are usually several groups of them. The nodules 
are prominently raised and usually rounded. (Fig. 93.) 
They are of a congested red or purple color. They may 
be hard and scaly ; or give exit to a sticky discharge ; or, 
rarely, suppurate. The hair over them is broken, or 
more or less wanting. Usually itching and burning are 
complained of. In some cases instead of distinct nodules 
we see a condition resembling kerion. The disease is usu- 
ally limited to the chin and anterior part of the neck. More 
rarely it involves the whole bearded portion of the face. 
Diagnosis. The disease is to be differentiated from 
sycosis, pustular eczema, and the tubercular syphilide. 
From sycosis it differs in affecting the lower part of the 
face and sparing the upper lip ; in presenting broken-off 
hair ; in having grouped nodules ; and in the presence of 
the fungus in the hair. Sycosis is more acute in its mani- 
festations, and is characterized by its many discrete pus- 
tules pierced by hair. From eczema it differs in the same 
points as it does from sycosis, and also in being less crusted, 
and in the ease with which the hair can be plucked or will 
break. Eczema is also a disease of the skin and not of the 
hair. The tubercular syphilide bears a resemblance to tricho- 
phytosis barbae at times. It differs from it in forming but 
a single group, in being of a darker color, and in under- 
going a steady course of development toward final recovery, 
leaving, not infrequently, permanent scars. Other symp- 
toms of syphilis will often be found, and its whole history 
will be different. 

Trichophytosis Unguium, or onycho-mycosis, is ring- 
worm as it affects the nails. It begins as a change in 



TRICHOPHYTOSIS UNGUIUM. 663 

color of the nail-substance and with a loss of its trans- 
parency. The nail becomes uneven and thickened, and 
its edge, which is usually the part first attacked, becomes 
raised from its bed by an accumulation of scaly matter 
under it. A progressive atrophy takes place, and at last 
the nail breaks and falls either in part or as a whole. 
There may be but one nail affected, or all the nails, both 
of the hands and feet, may be attacked, then usually con- 
secutively. Many obscure cases of atrophy of the nail 
will be found to be due to ringworm when the scrapings 
from them are examined under the microscope. 

Diagnosis. The appearances presented by the nails 
are so similar to those seen in psoriasis and other diseases 
in which the nails become atrophied, that a positive diag- 
nosis can be made by the microscope alone, unless there 
should be symptoms of the one or the other disease 
present elsewhere on the body as a guide. 

Having now described the different varieties of ring- 
worm with their differential diagnosis, we pass on to 
study the factors common to all. 

Etiology. The cause of the disease is contagion with 
the trichophyton fungus. This contagion may be direct, 
from person to person, or indirect by means of brushes, 
towels, clothing, and the like. It is possible that the air 
may become so full of the fungus in epidemics in crowded 
children's asylums that contagion may be by means of the 
fungus lighting upon the head or body. The disease is 
very contagious, much more so than is favus. 

As the disease is quite common in dogs, cats, and 
horses, constituting in them one form of mange, they are 
a very frequent source of contagion. Ringworm of the 
scalp is often communicated by means of brushes and 
headgear. Ringworm of the beard is conveyed by means 
of brushes, towels, and the barber's fingers. Ringworm 
of the nail comes from scratching. Some skins seem to 
furnish a better soil for the growth of the fungus than do 
others. Children have ringworm of the scalp ; adults 



664 



DISEASES OF THE SKIN. 



almost never. There is no peculiarity of constitution that 
predisposes to the disease. It attacks all classes and is seen 
in all conditions of society, though, of course, it is most 
common among the crowded poor. The gray non-inflam- 
matory patches on the scalp are caused by the micro- 
sporon Audouini, and the inflammatory form as well as 
Kerion are due to either the ectothrix or the endothrix 

Fig. 94. 




Trichophyton tonsurans in hair shaft and follicle. (After Kaposi.) 

forms of trichophyton. The last two also cause most 
cases of ringworm of the body and beard. Tinea imbri- 
cata is said to be due to an aspergillus. 

Pathology. The fungus of ringworm has its habitat 
in the epidermic structures of the skin. On the general 
cutaneous surface it is so superficially located as to be 
readily destroyed. When it attacks the hair and nails it 
penetrates below the skin in their epidermic structures, 
and is much more difficult of cure. 

The fungus (Fig. 94) consists in mycelia and conidia 
(spores) the proportion of which to each other varies; in 



TRICHOPHYTOSIS. 665 

the hair of the scalp and beard the number of spores far 
exceeds that of the mycelia. Sometimes they are so 
numerous as to be crowded together in lines. On the gen- 
eral surface the mycelia are far more numerous. They 
are long, slender, branched, straight or crooked bodies. 
The spores are round, small, and refract light. Having 
become lodged in the skin, the fungus always sets up a 
certain amount of irritation by its processes of growth. If 
it lands upon hairy regions, it attacks the hair secondarily, 
passing down the walls of the hair follicle to a greater or 
less depth before it penetrates the cuticle of the hair and 
gains access to its substance. Having gained access, it 
vegetates freely, and may often be traced throughout the 
whole length of the hair. Robinson and others have 
found the fungus in the peri -follicular tissue. Its pres- 
ence always causes more or less peri-folliculitis: If the 
peri-folliculitis is very great, permanent baldness may 
result. In trichophytosis unguium the fungus grows in 
the substance of the nails. 

Sabouraud * and others have demonstrated that there 
are several fungi producing ringworm, the most common 
being the trichophyton microsporon or microsporon au- 
douini, and the trichophyton endothrix and ectothrix. The 
endothrix fungus grows in the hair, while the ectothrix 
fungus grows about the hair forming a sleeve or cuff to the 
hair. C. J. White, 2 repeating Sabouraud' s investigations 
in this country, says that 52 per cent, of ringworm in 
this country is due to the microsporon, most all being on 
children's scalps. In England 90 per cent, of the cases 
are due to this form of trichophyton, and so the propor- 
tion varies in different countries. A similar fungus is 
found on animals. In the hairs the spores are small, 
round, glistening, and placed closely together. They are 
more equal in size than are those of the other forms of 
ringworm. Having penetrated the hair, the fungus 

1 Diag. et Trait, de la Pelade et des Teignes de l'Enfant. Paris, 
1895. 

2 Journ. Cutan. and Gen.-Urin. Dis., 1899, xvii., No. 1. 



666 DISEASES OF THE SKIN. 

grows in the hair substance in the form of long, jointed 
mycelia, fine branches from which, penetrating the cuti- 
cle, form ectospores on the surface of the hair. The 
microsporon does not grow well on the skin, but is found 
in some cases. The other forms of ringworm fungi 
rarely affect the scalp. The trichophyton endothrix in the 
hair grows in lines parallel to its long axis. Its spores are 
quadrangular, with rounded corners, and vary consider- 
ably in size. It has thus far been found only in humans. 
It causes most cases of ringworm of non-hairy parts, and 
some cases of ringworm of the scalp, especially those 
that have an eczematous appearance. The ectothrix 
variety most often affects the bearded portion of the 
face, and causes the deep or suppurating forms of ring- 
worm. It also produces kerion of the scalp, and many 
cases of trichophytosis corporis. The spores resemble 
the preceding, but grow around the hairs rather than in 
them. It is a pyogenic fungus, and is derived directly 
or indirectly from animals. The different forms of fun- 
gus show more divergence in cultures than in their 
natural state. 

Treatment. There is no disease of the skin much 
more easy of cure than trichophytosis of the general sur- 
face of the skin, and none much more difficult of cure 
than trichophytosis capitis. 

Trichophytosis corporis may be readily cured with al- 
most any slightly irritating and astringent application, 
and by all the antiparasitics. It may be cured by 
means of common ink, or by using vinegar in which a 
copper coin has been soaked. The scales should be 
removed with soap and water, and an ointment of sul- 
phur, or ammoniate of mercury, or chrysarobin, or pyro- 
gallol, be applied ; or simply paint the patch with tinct- 
ure of iodine, acetic or sulphurous acid, or a solution of 
bichloride of mercury, 3 to 5 grains to the ounce. The 
last is a good method for adults, as it does not stain the 
skin, and one application will usually cure the disease. 
It is rather too strong for children. Other applications 



TRICHOPHYTOSIS. 667 

are a saturated solution of hyposulphite of soda ; oleate 
of copper, J a drachm to the ounce of ointment ; and 
salicylic acid, 5 to 10 per cent, strength, which by no 
means exhausts the list. 

Trichophytosis cruris et axfflce, or eczema marginatum, 
is not so easy to cure as the preceding variety, but it can 
be cured by any of the means detailed above. In using 
chrysarobin, here as elsewhere, we should bear in mind 
its irritant qualities. Taylor has recommended painting 
the parts with 2 or 4 grains of bichloride of mercury in 
1 ounce of tincture of benzoin. Hardaway speaks well 
of modified AVilkinson's ointment. Some cases will make 
a good recovery under an ointment containing oil of 
cade, 1 drachm to the ounce. This is specially good 
after the use of sulphur or other antiparasitic to kill the 
fungus, as it is curative of the eczema that often remains. 

Trichophytosis capjitis is the most obstinate form of 
ringworm to cure. The fungus is present abundantly 
deep down in the skin, and each hair is a separate focus 
of disease. The difficulty we have to contend against is 
to cause our remedies to enter the skin deeply enough to 
destroy the fungus. Nature gives us a hint as to the 
cure of the disease when a kerion forms that is not infre- 
quently followed by disappearance of the disease. Most 
of the so-called remedies for ringworm are irritant to the 
skin, and do good quite as much by the irritation they 
cause as by their parasiticide properties. 

If we see the case at its earliest stage, we may some- 
times succeed in aborting the disease by the application 
of the bichloride of mercury, 5 or 10 grains to the 
ounce. Usually when the case is brought to us it has 
gone too far for aborting it. Then we may sometimes 
cure the case promptly, but most often it is an affair of 
months and, perhaps, years. The first requisite for a 
cure is faith on the part of the patient, so that the second 
element, persistency, can come into play ; and then by 
the persevering use of parasiticides a cure may be 
effected. As each case is a source of contagion, steps 



668 DISEASES OF THE SKIN. 

must be taken to isolate the case if it occur in an asylum 
or school. If it occur outside of an institution, the 
parents must be cautioned not to allow the child's hat or 
clothing to be worn by any other child, and the child 
must be taken out of school. To assure still further the 
safety of others, an antiparasitic must be applied to the 
child's head, such as a 1 or 2 per cent, solution of sal- 
icylic acid in alcohol and castor oil. The child should 
also wear a linen cap over the whole head. These regu- 
lations are difficult to carry out in private practice. 

The ringworm patch or patches should be scrubbed 
with soap and water so as to remove all the scales before 
we make any local application. Tar soap is a good one 
to use for the purpose. Then the hair should either be 
cut short, pulled from or shaved off the patches, and for 
about a quarter of an inch about them. Now the case 
is ready for the chosen parasiticide. Whatever is used 
in the form of an ointment or oil, it should not be 
smeared over the surface, but worked in, as it were. 
The remedies we use are exhibited in the form of oint- 
ments, oils, varnishes, pastes, solutions, and plasters. It 
is, unfortunately, necessary to give a lengthy list of 
remedies from which the reader may select. One of the 
oldest and most used of them is the officinal sulphur 
ointment, full strength or diluted according to reaction. 
Here, as elsewhere, when an ointment is mentioned, it is 
to be understood that it may be made with lard, vase- 
line, lanolin softened with oil, plasment (mucilage of 
Irish moss), or gelanthum. The last is to be preferred 
because it is not greasy, sinks readily into the skin, and 
leaves a slight film over the patches that prevents, to a 
certain extent, the escape of the spores into the air. The 
persistent daily use of sulphur ointment, combined with 
epilation, and scrubbing of the patch with soap and 
water about once a week, will cure the disease. Sulphur 
may also be used in combination with other drugs. One 
of the most efficient remedies in chronic, obstinate cases 
is 



TRICHOPHYTOSIS. 669 

R 01. tiglii, 23; 41 

Ungt. sulphuris, ^j ; 30( M. 

This is to be rubbed into the patch once a day until symp- 
toms of reaction appear, the patch becoming swollen and 
red. When this subsides the patch will be smooth like as 
in alopecia areata. There is always danger of producing 
permanent baldness, but thus far in all my cases the hair 
has come in all right. As nothing has yet been found to 
render sulphur soluble in any amount, it must always be 
exhibited in ointment- or paste-form. 

Mercury is another old stand-by. It may be used as a 
solution of the bichloride in alcohol (grs. j-iij ad §j), whose 
application should not be intrusted to any one but a physi- 
cian or trained nurse. It is to be used two or three times 
a day, its effect carefully watched, and, of course, it should 
not be applied to large surfaces. It may be employed as 
recommended by Kerley, 1 who reports having cured a 
number of cases in from two to twenty weeks by using a 
solution made by adding 2 grains of the bichloride dis- 
solved in sufficient alcohol to J ounce each of kerosene 
and olive oil, daily rubbed into patches as well as applied 
all over the scalp. When inflammation is caused, the 
application is stopped, and a simple ointment is used until 
the irritation subsides. Then the bichloride is again 
applied. The scalp is to be washed often. He thinks that 
a cure will be hastened by using a saturated solution of iodine 
on alternate days with the bichloride solution. Crocker 
thinks highly of the bichloride, 3 grains dissolved in 
alcohol, to the ounce of turpentine. Tincture of benzoin 
is a good excipient for the bichloride, according to Levi- 
seur, 2 who recommends the application of it 1 to 2 parts 
to 300 parts of benzoin, once a week, with the daily use 
of salicylic acid ointment in 10 to 20 per cent, strength. 
All the mercurial ointments are useful, but are not so 
prompt in their action as other remedies. 

The remedies recommended in the treatment of ring- 

1 New York Med. Journ., 1891, liv., 396. 

2 Med. Kec, 1889, xxxv., 594. 



670 DISEASES OF THE SKIN. 

worm of the body are all of use in the same disease of the 
scalp, and need not be repeated here. The main modi- 
fication is the epilation that should precede their applica- 
tion. Instead of using tincture of iodine, the English 
authors commend Coster's paint, made of 2 drachms of 
iodine and 6 drachms of the light oil of wood- tar, which 
is to be firmly applied with a stiff brush. A black crust 
will form after two or three days, which should be re- 
moved with the forceps. The part should then be washed 
with soap and water, and the paint again applied. Two 
or three applications of it may be made to an infant's 
scalp, or it may be continued longer in children over four 
years of age. The best way of using iodine, and in my 
experience the best treatment for ringworm, is to rub up 1 
drachm of the crystals of iodine in 1 ounce of goose-grease. 
This is to be well rubbed into the patches with a stencil- or 
stiff paint-brush. It causes but little reaction and cures 
speedily. The iodine is found staining the hairs deeply 
when the hairs are examined under the microscope. 

Chrysarobin in 1 per cent, strength in traumaticin or 
collodion is good, its tendency to produce dermatitis beiDg 
ever borne in mind. It may be suspended in glycerin and 
painted on once daily until redness and swelling appear. 
Then olive oil is to be applied until the reaction subsides. 
Then the part is to be washed with soap and water and 
the chrysarobin reapplied, and so continued until a cure 
is affected. Pyrogallol in 5 to 15 per cent, in the same 
excipients, with or without the addition of \ a drachm 
of salicylic acid to the ounce, is a reliable preparation. 
ft-naphtol and hydronaphtol are commendable. Naphtol 
may be used as a 1 per cent, solution in alcohol, or in the 
form of a paste, as recommended by Kaposi : * 

R 



M. 



/3-NaphtoL, 


gr. xv ; 


1 


Spt. sap. viridis, 


gr. xxx; 


2 


Alcohol., 


Jjss; 


50 


Bals. peruv., 


gr. xxx; 


2 


Sulph. loti, 


Sijss ; 


10 



1 Wien. med. Wochenschr , 1881, xxxi., 617. 



TRICHOPHYTOSIS. 671 

Either may be applied twice a day for two or three days, 
and then followed by a thorough scrubbing with green 
soap. Thymol in 5 to 10 per cent, strength, dissolved in 
chloroform, and olive oil, is recommended by Malcolm 
Morris. Formalin is commended by some, but con- 
demned by others, on account of the severe irritation it is 
capable of setting up. 

Harrison l endeavored to effect entrance of his remedies 
to the deeper parts of the skin by first applying to the 
scalp solution No. 1, composed of J a drachm of potas- 
sium iodide in 1 ounce of liquor potassse. After a few 
days he applied solution No. 2, composed of 3 grains of 
corrosive sublimate to 1 ounce of sweet spirits of nitre or 
of water. This treatment requires careful watching. 
Foulis 2 recommends rubbing turpentine into the scalp, 
after cutting the hair, until it smarts. Then the scalp 
is to be scrubbed with 10 per cent, carbolic soap, dried, 
and painted with two or three coats of tincture of iodine. 
When dry the whole head is to be anointed with carbol- 
ized oil, 1 : 20. This procedure is to be carried out once 
a day. Alder Smith has found useful a saturated solution 
of boric acid, as follows : 



R 



Ac. boric, 


3iv; 


15 


iEtheris, 


3v; 


150 


Alcoholis, 


ad 3x1; 


ad 600 



M. 



It is to be freely applied after washing the head in the 
morning, and two to five times during the day. 

H. B. Sheffield 3 recommends clipping the hair close, 
and applying over the whole scalp once a day for five days 
R Ac. carbolici, 



01. petrolati, j aa ^ DO ' Ea 15 
Tinct. iodini, "1 

Ol.ricini, / a & 5 ** 30 

01. rusci, ad^iv; ad 120 



M. 



This is to be wiped off with a cloth on the sixth day, the 

1 Bri. Med. Journ., 1885, ii., 134. 

2 Ibid., 1885, i., 536. 

3 New York Med. Journ., 1898, lxvii., 680, 



672 DISEASES OF THE SKIN. 

hair clipped, and the scalp thoroughly washed with green 
soap. On the seventh day the treatment is to be re- 
peated, and so on for three or four weeks, or until no more 
fungus is found and new hair appears. A 10 per cent, 
sulphur ointment is then to be used for a few days, and 
for two weeks afterward 

R Resorcin., . ) . i 

Ac. salicylic!, J aa & 5 aa 4 
Alcoholis, ^j ; 30| 

Ol. ricini ad ^iv, ad 120 i M. 

In very chronic cases and in the disseminated form it 
may be necessary to blister the patch by means of croton 
oil or acetic acid. Croton oil must always be used with 
caution and to small areas, as it is capable of producing 
permanent baldness. One part in ten of olive oil is usu- 
ally sufficient, but the strength may be increased till we 
have it sufficiently strong to cause a mild degree of pus- 
tulation, when the hairs may be easily plucked. In dis- 
seminated ringworm a drop of the pure oil may be applied 
to each diseased follicle, and as soon as a pustule forms 
the hair should be pulled out. Whitfield advises using 
for this purpose, a No. 1 6 sewing needle bent to an augle 
of 45 degrees, dipping the eye end into the oil, and pass- 
ing it into the follicle. The hair is to be pulled out in a 
few minutes. In very obstinate cases electrolysis may 
be employed to individual hairs, which, like the croton 
oil, will permanently destroy the hair. A. Van Har- 
lingen 1 advises the use of a 10 to 20 percent, tincture or 
ointment of epicairin rubbed in twice a day and claims to 
cure the disease in five weeks. Others have had the 
same experience. 

Epilation is of positive value in treating this obstinate 
disease, even though the hair does break off. Some hair 
with its fungus will come out, and the follicular mouths 
will be rendered more open for the entrance of the appli- 
cations, which should always follow epilation. Besnier 
epilates around the patches, and asserts that then the dis- 
i Amer. Journ. Med. Sci., 1903, cxxv., 1012. 



TRICHOPHYTOSIS. 673 

ease rarely spreads to neighboring parts. The Rontgen 
rays from a soft tube may be used for the purpose of 
epilation and cure. The method has been perfected by 
Sabouraud and Noire. They place the patient at 1 5 cm. 
from the anticathode of a self-regulating Miiller tube of 
8 cm. diameter. At 7J cm. from the anticathode they 
place in a proper holder a pastile made of bristol board 
coated with an emulsion of platino-cyanid of barium in 
collodion with acetate of starch. This is covered with 
black paper. The exposure is continued until the pastile 
assumes the tint of a standard color " B," which comes 
with the book holding the pastiles. But one exposure is 
made. In fifteen days the hair falls. In two months it 
comes in healthy. During this time the head is covered 
with an antiseptic wash. In this country these pastiles do 
not work well, and most operators proceed as in the 
treatment of hypertrichosis, care being had to avoid any 
violent reaction. 

Treatment should be continued until there are no more 
stumps or broken-oif hairs to be seen ; till the microscope 
fails to reveal any fungus in the hair after prolonged 
search, and until the scalp is no more scaly. It is well 
to use the following : 

R Hydrarg. ammon., J} j ; 133 

Hydrarg. chlor. mitis, ^ij ; 2 66 

Vaselini, gj ; 32 M. 

or a sulphur ointment for several months after apparent 
cure. 

Trichophytosis barbce is treated along the same lines as 
when the scalp is the seat of the disease. The beard 
should not be shaved, but cut short with scissors Here 
epilation is of more positive value, as the hairs over the 
nodules will come out easily. It is possible to abort the 
disease before it has implicated the hair by the applica- 
tion of a solution of 5 to 10 grains of bichloride of mer- 
cury in alcohol. A 10 per cent, solution of resorcin or 
an ointment of the same strength may accomplish the 
same end. After the disease has got fully under way, 
43 



674 DISEASES OF THE SKIN. 

systematic epilation, daily shaving by the patient himself, 
and the thorough application of one of the parasiticide prep- 
arations mentioned in the preceding section, especially 
the iodine goose-grease, will effect a cure. X-rays may be 
used as in ringworm of the scalp. 

Trichophytosis unguium may be treated by producing a 
paronychia. This may be done by Pellizzari's l method 
of keeping green soap upon the nail under a rubber cot 
for a few days, until the nail is softened. Then equal 
parts of olive oil and pyrogallol are to be applied till 
the nail loosens, when it is to be removed and the finger 
dressed with iodoform. Thin 2 recommends scraping the 
affected nails very thin, applying liquor potassse to soften 
them, and then dabbing on creosote, or acetic acid, or a 
solution of 2 to 5 grains of bichloride of mercury in 
alcohol. Crocker speaks well of using Harrison's plan 
for treating ringworm of the scalp, which see. Solution 
No. 1 should be applied after scraping and kept on for 
fifteen minutes, covered with oiled silk; then No. 2 
applied in the same way and kept on for twenty-four 
hours. These should be repeated till the cure is effected. 
If the skin should become tender or begin to peel, the 
solutions should be stopped, and one of hyposulphite of 
soda used until the skin heals. A 10 per cent, salicylic 
acid plaster worn constantly over the nail and thrust 
under it is a good remedy. 

Prognosis. All forms of ringworm, excepting that of 
the general surface of the body, are very obstinate, but 
persevering and intelligent treatment will cure them all. 
The most obstinate form is that of the scalp, and a speedy 
cure should never be promised. It must always be 
remembered that as puberty is reached it tends to spon- 
taneous cure. 

Trichoptilosis. ") 

Trichorrhexis Nodosa. V See Atrophia pilorum propria. 

Trichoxerosis. J 

i Giorn. Ital. d. Mai. e del Pelle, March, 1888. 
2 Practitioner, May, 1887 et seq. 



TUBERCULOSIS VERRUCOSA CUTIS. 675 

Tubercula Miliaria. \ a -vr-v 

Tubercula Sebacea. J 

Tubercula Anatomique. See Tuberculosis verrucosa cutis. 

Tuberculosis Cutis Vera. Synonyms : T. ulcerosa ; 
Miliary tuberculosis of the skin ; T. cutis orificialis. 

Symptoms. This is a rare disease, having been met 
with by Chiari but 5 times in between 3000 and 4000 
post-mortems of those who had died of tuberculosis. It 
occurs almost exclusively about the mucous orifices — 
mouth, anus, vulva, and glans penis. Crocker describes 
the disease as follows: "The lesions consist of one or 
more discrete, shallow, not painful ulcers, which form 
apparently spontaneously, have an irregular, eroded, 
moderately infiltrated edge, and when the crusts, which 
soon cover them, are removed, show a reddish-yellow, 
granular surface, with a thin, scanty secretion. They 
never heal, but spread slowly and continuously, and may 
coalesce with neighboring ulcers, becoming serpiginous ; 
they may thus extend over an area of one or more square 
inches ; but, as a rule, they are small. When on mucous 
membranes, yellow miliary papules exist near them." 
They are due to local infection with the tubercle bacillus, 
and are a part of a general tuberculosis. Their diag- 
nosis is difficult, though their nature may be suspected 
on account of the other and evident symptoms of the 
primary disease. 

Treatment. Treatment is unavailing, though iodol, 
iodoform, or aristol may be applied. 

Tuberculosis Verrucosa Cutis. Synonyms : Verruca 
necrogenica; Lupus verrucosus; Scrofuloderma verruco- 
sum ; (Fr.) Lupus sclereux, ou 1. papillaire verruqueux ; 
Anatomical tubercle ; Post-mortem warts. 

These names have been given by different writers to 
what may be regarded as simply varying aspects of the 
disease described by Riehl and Paltauf * as tuberculosis 
verrucosa cutis. 

i Vierteljahr. f. Derm, u. Syph. ? 1886, xiii., 19, 



676 



DISEASES OF THE SKIN. 



Symptoms. 1 The disease occurs usually in the form 
of a single round or oval patch. There may be several 
such patches. If two patches join, irregularly shaped 
patches, with scalloped border, may form, and perhaps 
become serpiginous. In size the single patches vary from 
that of a lentil up to that of a silver half-dollar. Around 
the patch is a narrow zone of erythema, of a bright red, 

Fig. 95. 




Tuberculosis verrucosa cutis. (After Hyde.) 

that disappears under pressure. Its surface is smooth, 
and often more shiny than the normal skin. Toward the 
next zone it is slightly elevated. Its follicular openings 
are preserved. 

Inside of this zone is a row of small, discrete, super- 
ficial pustules, whose covers are so thin that they break 
easily, and we find only the crusts and scales left by them. 
The color of this zone is brown or livid red, and it can- 
Dot be pressed out entirely, showing that there is some 
infiltration of the skin. This zone is slightly raised, but 

1 The description here given is taken, for the most part ? from the 
above-mentioned article by Riehl and Paltauf, 



TUBERCULOSIS VERRUCOSA CUTIS. 677 

the one to its inner side is markedly so. It has also an 
irregularly knobby surface, becoming distinctly warty 
toward the centre of the growth, the warts being rounded 
or pointed. The nearer the centre the warts are the 
larger they are, some of them being 5 to 7 milli- 
meters long. The whole surface of this zone is more or 
less scaly or crusted. The color is brownish-red. The 
warty growths are often close together with fissures 
between them, and little erosions and pustules. If the 
patch is pinched up between the fingers, little drops of 
pus may be made to well up from between the papillae. 
The mouths of the follicles are destroyed. In some 
cases acute inflammation may occur, and the patch will 
swell up and become more angry-looking. 

After a time the patch begins to flatten in the middle 
by the disappearance of the warty growths, and at last 
becomes changed into a smooth or slightly scaling cica- 
trix, which is thin and soft, with a delicate sieve- or net- 
like appearance. 

The patch is always freely movable upon the under- 
lying parts, and usually gives rise to no subjective symp- 
toms. Sometimes pain is complained of on pressure. 
The growth is by the addition of new lesions on the 
periphery of the old patch, and is usually very slow, and 
at intervals with pauses between. It is a chronic affec- 
tion, showing no tendency to spontaneous recovery. 

Such are the typical disease and its course. In the 
description of the different diseases named above will be 
found some deviations from the type, but they all agree 
in the main, and are probably all one and the same dis- 
ease. It is met with most often upon the back of the 
hands and fingers, but may occur anywhere. 

Etiology. The cause of this form of tuberculosis is 
the inoculation of the skin with the tubercle bacillus, 
which has been found in sections taken from the patches. 
The disease is seen most frequently in men, and is spe- 
cially prevalent in butchers and those who have to do 
with animals, such as hostlers and drovers. Dead-house 



678 DISEASES OF THE SKIN. 

attendants are also its victims not infrequently. Cases 
have been directly traced to inoculation with tubercular 
tissue. 

Pathology. The chief histologic distinction between 
this form and lupus, is that while in the latter the foci of 
granulation tissue lie in the lower and middle portions of 
the corium, in tuberculosis cutis they are quite constantly 
found in the papillae and upper papillary layer. 

Moreover in tuberculosis cutis miliary abscesses, due 
to the secondary invasion of the pus cocci, occur imme- 
diately below the rete. Tubercle bacilli may be scarce 
or plentiful. 

Diagnosis. Though allied to lupus, it differs from it 
in the entire absence of the characteristic lupus tubercles, 
and of the tendency to ulceration ; in the manner of heal- 
ing in the centre by a scar in which no relapse takes 
place ; in its superficial situation in the skin ; in the 
purulent matter that can be squeezed out from between 
its papillae ; and in the relatively late time of life at which 
it appears. From syphilis it differs in its more chronic 
course ; in the absence of a Avail of infiltration about it ; 
in its color ; and in showing no tendency to break down 
and ulcerate. 

Treatment. The growth may be curetted away, and 
the wound afterward treated with pyrogallol, as in lupus. 
Or it may be destroyed by the galvano-cautery or by elec- 
trolysis. Or it may be covered with 25 per cent, salicylic- 
acid-creosote plaster. Crocker advises the use of this 
plaster, to be followed with the fuming nitrate of mercury 
applied with a piece of wood. I have found the plaster 
sufficient in itself. Or it may be destroyed by any pow- 
erful caustic, but it must be destroyed entirely or it will 
crop out again. Radiotherapy is indicated. 

Prognosis. The disease is more easily curable than is 
lupus, and, as a rule, the growths are readily removed. 

Tumeurs Folliculeuses. See Molluscum sebaceum. • 
Tyloma, seu Tylosis. See Keratosis palmaris et plantaris. 



ULCERS. G79- 

Tylosis Lingugs. See Leucoplakia. 

Ulcers. Ulceration is a symptom common to many dis- 
eases, such as lupus, syphilis, scrofulodermata, and other 
destructive processes. For these the reader is referred to 
the sections treating of the disease of which they form a 
part. I shall here deal briefly with those ulcers of the 
leg that form so large a part of every dermatological 
clinic, and are usually called varicose ulcers. They are 
located most often over the anterior surface of the leg 
and on its lower half. They may be superficial or deep. 
They are irregular in shape with sloping or undermined 
edges, and with a more or less wide zone of redness and 
infiltration of the skin about them. Their bases may be 
covered with flabby granulations ; or be smooth and glazed, 
with thin, scanty secretion ; or they may discharge a great 
deal of sero-puruleut matter. Some of them bleed read- 
ily, some do not. There may be but one ulcer, or there 
may be several of them. One or both legs may be affected. 
The ulcers may be small, or so large as to encircle the leg 
and occupy more than half its length, and they may at- 
tain this size either by gradual extension of themselves 
or by the junction of several ulcers. • They begin not 
infrequently as a number of small shelving ulcers on a 
red and densely infiltrated base. These enlarge rapidly 
and form a large ulcer. The patient complains of more or 
less spontaneous pain, and the ulcers are often very tender. 
The foot and leg are sometimes greatly swollen and feel 
brawny. It will be noted that the foot and leg are marked 
with dilated veins, and varicosities can be felt sometimes 
like whip-cords under the skin. The deep veins are gen- 
erally swollen at the same time, though they cannot be 
felt so readily. Usually both legs are affected. 

Etiology. These ulcers are predisposed to by stand- 
ing for hours at a time, and it is standing in one position 
that is particulary obnoxious. It is therefore in car- 
drivers, blacksmiths, cooks, and those following similar 
occupations that ulcerations are prone to occur. A loaded 



680 DISEASES OF THE SKIN. 

condition of the portal circulation and constipated bowels 
also favor varicosities and the occurrence of ulceration. 
On account of the chronic, congested condition of the leg, 
some slight traumatism that in the normal state would 
produce hardly appreciable damage will be followed by 
a breaking down of the tissues and an ulcer. 

Diagnosis. It is most important to diagnose a varicose 
ulcer from one due to syphilis, as they require different 
treatment, and have a different prognosis. The syphilitic 
ulcer is usually located upon the upper half of the leg, and 
toward its posterior surface, or about the knee. It has an 
infiltrated border, but by no means as broad a one as the 
varicose ulcer. It lacks the marked inflammatory symp- 
toms of the varicose ulcer, and is "punched-out looking" 
with perpendicular ridges. It is round, or, if formed by 
the coalition of several softened tubercles, it will have a 
scalloped edge, indicating its origin from several distinct 
lesions. As a rule, it is quite painless, and there are several 
ulcers on one leg, the other being free. 

Treatment. If we can confine our patient absolutely 
to bed, and keep the leg snugly and evenly bandaged, the 
ulcers will heal under simple dressings. This we cannot 
do with most of our cases. Bandaging the leg from the 
toes to the knee is an essential in their successful manage- 
ment, an ordinary roller-bandage being used as long as 
any greasy applications are made. In ulcers connected 
with varicose veins, after acute symptoms have subsided, 
bandaging from the toes to the knee with a rubber band- 
age is excellent. So too in all ulcers is the continuous 
bath with warm water, or by means of cloths wrung out 
of hot water, frequently renewed and covered with oiled 
silk. 

One of the oldest and best treatments for ulcers is to 
touch them daily with balsam of Peru and cover them 
with oxide of zinc ointment, or, better, with Lassar's 
paste. Dry dressings for the ulcer are preferable to 
greasy applications, and for this we may use iodoform, 
iodol, aristol, subnitrate or subiodide of bismuth, or der- 



XJLEU YTHEMA. 681 

matol, or any of the later antiseptic or stimulating pow- 
ders. If there is any eczema or dermatitis about the 
ulcer, it is requisite to cover the powder and the whole 
patch with some mild or stimulating ointment according 
to the state of the skin. In this case the ulcer must be 
dressed once or twice a day. If there is not much der- 
matitis, we can dispense with the ointment, and dress 
the leg antiseptically and leave it for several days. Ap- 
plications of nitrate of silver may be used to stimulate 
an atonic ulcer or to smooth down exuberant granula- 
tions. Strapping with adhesive plaster is another excel- 
lent means of treating ulcers upon not very much in- 
flamed bases. Skin grafting according to Thiersch's 
method, is the most prompt and sometimes the only way 
to cause large ulcers to heal. For further surgical treat- 
ment of ulcers text-books on surgery must be consulted. 

Ulcer, Oriental. See Aleppo boil. 

Ulcer, Perforating, of Foot. See Perforating ulcer of 
foot. 

Ulcer, Tropical Phagedenic. This is an ulcer secondary 
to a lesion of the skin that occurs in the tropics, and is 
marked by rapid extension and gangrenous destruction of 
tissues. It may be mild or malignant in its course. The 
latter eats deeply, involving even the bones. 

Ulcus Rodens. See Epithelioma. 

Ulcus Grave. See Fungus foot of India. 

Ulerythema. This is a name proposed by Unna for 
those diseases in which there is a more or less persistent 
erythema upon which follows cicatrization by a process of 
absorption of inflammatory infiltration, and without ulcer- 
ation. Under this heading comes lupus erythematosus. 
Ulerythema sycosiforme 1 and ulerythema ophyrogenes 2 are 
two other varieties of this form of disease. They bear a 
resemblance to the "folliculitis decalvans" of the French. 

1 Monatshefte f. prakt. Dermat., 1889, ix., No. 3. 

2 Ibid., No. 5. 



682 DISEASES OF THE SKIN. 

They both affect hairy regions, the first having a predilec- 
tion for the beard, and the second for the eyebrows. In 
their course they present symptoms somewhat like sycosis, 
but differ from that disease in causing permanent bald 
patches, and the destruction of the skin so as to form 
cicatrices. 

Ulerythema acneiforme is the name given by Unna 1 to 
a purely local, probably parasitic, disease of the skin 
which is limited to the neighborhood of individual hair 
follicles. It begins as an inflammatory erythema, which, 
after persisting for some time, leads either to the forma- 
tion of a well marked cornification of the cuticle and 
comedones, or to cicatricial atrophy. 

It differs from acne in beginning on the middle of the 
cheek and margin of the auricle ; in extending to the 
hairy scalp ; in being primarily an inflammatory ery- 
thema ; in an absence of suppuration, and in atrophy 
occurring without suppuration. It differs from acne ne- 
erotica in complete absence of necrosis, suppuration, and 
ulceration ; in prominence of comedones ; and in having 
no resemblance to variola in its scar. 

Uncinarial Dermatitis, or ground itch, is due to the inva- 
sion of the skin by nectator Amerlcanus or hook worm which 
lives in the mud in some tropical countries. It attacks 
those who go bare foot. It causes itching, followed by 
redness and swelling, papules and vesicles. In bad cases 
pustulation may take place, and extensive ulceration 
leaving scars. In mild cases the dermatitis subsides in 
one or two weeks. Systemic infection may take place 
marked by prostration, pains in the epigastrium, short- 
ness of breath, palpitation, and fever. It may cause 
death with symptoms of profound anaemia. The treat- 
ment of the dermatitis is along the usual lines. Anthel- 
mintics are indicated for the constitutional infection. 

Uridrosis. Synonym: Sudor urinosis. By this is meant 
the excretion by the sweat pores of sweat loaded with the 

3 Internat. Atlas of Rare Skin Diseases, No. 1. 



URTICARIA. 683 

constituents of the urine, specially urea. The sweat then 
often has a urinary odor, and deposits crystals of urates 
upon the skin. It is always a complication of some grave 
general disease. 

Urticaria. Synonyms: Cnidosis; (Fr.) Urticaire; (Ger.) 
Nesselsuch, Nesselausschlag, Porcellanfriesel ; (Eng.) JNet- 
tlerash, Hives. 

An acute or chronic disease of the skin characterized 
by the appearance of wheals. It may run an acute or 
chronic course. 

Symptoms. The vast majority of cases run an acute 
course. The characteristic feature of the disease is the 
appearance of wheals — that is, firm, flat, circumscribed ele- 
vations of the skin which are at first pink, and then white. 
They may remain pink. They may be round, oval, annu- 
lar, or elongated, and are always surrounded by a red 
areola. They vary in size, sometimes being no larger than 
the head of a pin, papular uticaria, and sometimes of the 
diameter of an inch. They show no tendency to group, 
but are irregularly disseminated over the whole body. 
Though they are not symmetrical in distribution, both 
sides of the body are affected at the same time, and they 
show some preference for the extensor surfaces of the 
arms and legs. They itch, burn, and tingle, and are 
always scratched. They are ephemeral, each lesion last- 
ing but a short time — from a few minutes to a day. Ex- 
ceptionally some wheals will last several days. New 
lesions crop out as old lesions fade, and thus the eruption 
is continued. The mucous membranes are often affected 
at the same time with the skin ; and if the pharynx is 
attacked there may be suffocative symptoms. The dura- 
tion of the disease as commonly met with is but a few 
days, and not infrequently the wheals may be entirely 
absent during the day ? to break out again at night. Very 
often when the patient is seen by the physician, he can 
find nothing but scratched papules. But the patient will 
tell him that when he is undressing, or is warm in bed, 



684 DISEASES OF THE SE1K 

the itching becomes unbearable, and lumps looking like 
mosquito-bites break out upon him. The skin of a patient 
with urticaria is very irritable, so that a sharp tap upon 
it or drawing the nail across it will produce a wheal. 

The outbreak of the disease may be sudden without 
constitutional disturbance, or there may be some burning 
and tingling of the skin before its appearance. Or there 
may be some febrile movement, and some evident dis- 
turbance of the digestion, such as vomiting or dyspeptic 
symptoms. When the disease is cured the lesions dis- 
appear without desquamation, and leave no trace. Such 
is the acute form. 

Chronic urticaria differs from the acute form mainly 
in its duration. Instead of recovery taking place in a 
few days or weeks, its course is one of months and years. 
Sometimes the outbreaks of the eruption show marked 
periodicity, occurring at stated intervals after pauses of 
complete immunity. The eruption is generally not so 
extensive in the chronic as in the acute form. If the 
itching has been very severe and the scratching propor- 
tionally excessive, the skin may become pigmented, as in 
other chronic pruritic diseases. 

The wheals assume different appearances in different 
cases, and different adjectives are used to express the 
varying pictures. It is not necessary to burden the 
mind with these, though they are convenient for descrip- 
tive purposes. Thus we have urticaria tuberosa seu 
gigans, where the lesions are unusually large ; urticaria 
bullosa, where the wheals are surmounted by bullae ; 
urticaria hemorrhagica, where hemorrhage into the 
wheals occurs ; urticaria oedematosa, probably the same 
as acute circumscribed oedema or acute angioneurotic 
oedema, where the wheal occurs in locations in which the 
subcutaneous tissues are lax, as about the eye, nearly 
closing it, or on the tongue, causing it to swell enorm- 
ously and threaten suffocation ; urticaria papulosa, or 
lichen urticatus, where the wheals are small, a form com- 
mon about the buttocks of children. 



URTICARIA. 685 

Urticaria factitia is the name used to express the fact 
that, on account of the irritability of the skin, a wheal 
may readily be excited by local irritation. Urticaria 
perstans simply refers to the persistent character of the 
single lesion. Urticaria maculosa is the name proposed 
by Fournier for that form in which the wheal remains 
red. 

Etiology. The causes of the disease are more numer- 
ous than the forms it may assume. Most of the acute 
and many of the chronic cases are dependent upon irri- 
tating ingesta, such as shell-fish, strawberries, cheese, 
pickles, mushrooms, pork, sausages, even mutton in some, 
and almost anything in other people, it being largely a 
matter of idiosyncrasy ; medicinal substances, such as 
quinine, cubebs, copaiba, salicylic acid, opium, and other 
drugs. The rupture of hydatid cysts has been followed 
by urticaria. Dyspepsia in its various forms, and con- 
stipation, are common factors, especially in chronic urti- 
caria, as are intestinal worms in children. So also at 
times may be disorders of the liver, uterus, and ovaries. 
Some very severe cases occur during pregnancy. Some 
cases seem to be purely emotional in origin. Gout, rheu- 
matism, malaria, and functional or organic diseases of 
the nervous system will be found at the bottom of many 
cases of chronic urticaria. Wright holds that diminu- 
tion in the lime salts in the blood that interferes with its 
coagubility is the cause. 

Not only do we have internal causes producing the 
disease, but also external causes, such as contact with the 
jelly-fish ; crawling of caterpillars ; the action of cold, or 
sudden changes of temperature ; the galvanic current ; 
and bites of insects. Urticaria is a common accompani- 
ment of scabies and pediculosis. 

Pathology. Urticaria is due to a vasomotor dis- 
turbance. At first there occurs a spasmodic contraction 
of the vessels of a circumscribed area of the skin, which 
is followed by paralytic dilatation of the vessels and re- 
tardation of the circulation, Serous exudation ensues, 



686 DISEASES OF THE SKIN. 

forming the wheal, which at first is pink, and then be- 
comes white, on account of the pressure of the fluid forc- 
ing out the blood from the central parts of the wheal. 
"When the paresis ceases, the serous exudation is ab- 
sorbed and the part returns to its normal condition. T. 
C. Gilchrist. 1 Torok, and others do not believe in the 
vasomotor theory of the disease, but think that it is an 
inflammation of the skin, due to the escape of some 
toxin from the blood into the derma. J. Baum 2 has pro- 
duced wheals experimentally in frogs. He found that 
the capillaries dilate and fill with blood, the arteries dilate 
slightly and the veins more. Their circulation grad- 
ually becomes slower, till stasis occurs at the periphery 
of the wheal. In ten to twenty minutes the wheal 
appears on accounnt of oedema of the part. 

Diagnosis. The occurrence of wheals is pathogno- 
monic of urticaria, as they occur in no other disease. 
When they are present there is no difficulty in diagnosis. 
When they are not present and we find only scratch- 
marks we have to decide whether we have to do with 
urticaria or eczema, scabies, pediculosis, or dermatitis 
herpetiformis. Eczema differs from urticaria in the ten- 
dency its lesions have to run together and form patches. 
It never could be so generally distributed without pre- 
senting some characteristic patches. Scabies shows scratch- 
marks on the hands and feet, between the fingers and 
toes, in the axilla?, about the umbilicus, and on the breasts 
of the female and the penis of the male. The cuni- 
culi may be found in most cases. Pediculosis shows 
long parallel scratch-marks over the back, between the 
shoulders, along the. outside and inside of the limbs 
where the seams of the clothing come, and about the 
waist. Dermatitis herpetifo?'mis presents grouped lesions, 
which usually are vesicles, but may be papules. Erythema 
of papular or tubercular variety may resemble urticaria, 

1 Journ. Amer. Med. Assoc, 1896, xxvii., 1222, 

2 Berlin, Klin. Woch., 1905, xlii., 9, 



URTICARIA. 687 

but it is a markedly symmetrical disease, and burns 
rather than itches. 

Treatment. In acute urticaria the administration 
of a prompt cathartic or saline laxative will usually cure 
the disease if due to some irritating ingesta. .Emetics 
may be useful, if we see the case before stomachic diges- 
tion is ended, but in most cases we are called in when it 
is too late for them to be of service. Saline laxatives, 
mineral acids, the rhubarb and soda mixture, salol, 
resorcin, creosote or other intestinal disinfectants are of 
service in the more chronic cases. Of course, if the 
eruption is due to the ingestion of drugs, they must be 
stopped. 

In chronic cases, besides medicinal treatment we must 
regulate the diet, studying each case by itself. It is 
often well to put the patient on a strictly milk diet for a 
few days, and then add other articles with care. Alco- 
holics in all forms, and especially beer or other malt 
liquors, should be prohibited. If the gouty or rheumatic 
diathesis is at the foundation of the trouble, it must be 
combated. If the outbreak shows marked periodicity, 
sulphate of quinine may do good. Salicylate of soda 
and alkaline diuretics and laxatives sometimes do good 
service even when there is no evident rheumatic 
tendency. In fact, we must endeavor in every way to 
get our patient into a normal state of health. Whitfield 
advises giving calcium lactate The most difficult class of 
cases are those in which a neurosis alone seems to be the 
cause. Then belladonna, atropia, arsenic, the bromides, 
antipyrin, phenacetin, and galvanism may be tried. Pilo- 
carpi^ wine of antimony, colchicum, ergot, are also com- 
mended. It may be necessary to procure sleep in some 
cases by giving bromides, sulphonal, and the like. 
Opium is to be avoided. In very obstinate cases the 
patient should be sent away from home and relieved from 
all business cares. 

Local Treatment is of great service in allaying the 
itching, but it will not cure the disease. The parts may 



688 DISEASES OF THE SKIN. 

be sponged with alkaline lotions, such as a teaspoonful of 
baking-soda to a hand-basinful of water. Sometimes more 
relief is obtained by an acid solution, such as vinegar, 
pure or with water. Carbolic acid in vaseline, or alcohol 
and water, is sometimes very efficacious. In vaseline, 10 
per cent, strength is sufficient ; in lotion-form we may 
use, to the adult skin, 1 to 2 drachms to the ounce, direct- 
ing the patient to dab and not rub it on the skin. Harda- 
way prefers using the acid in a spray, 2 to 4 drachms to 
the pint, with 1 ounce of glycerin. To each atomizerful 
10 drops of oil of peppermint may be added to increase 
its antipruritic qualities. Menthol, 1 to 10 per cent, in 
alcohol or almond oil, is said to be efficacious. Crocker 
speaks highly of liquor carbonis detergens, 5j to §iv ; 
terebene, 5iv to §iv ; and equal parts of sanitas and 
water. Salicylic acid, 20 grains to the ounce of caster 
oil, is good, but disagreeable. Camphor and chloral 
hydrate, each from J to 1 drachm, rubbed together and 
added to 1 ounce of starch or ungt. simplex, is another 
good antipruritic. Chloroform dabbed or sprayed on 
renders prompt relief. Baths are sometimes of use. 
Having the patient take a warm bath containing either 2 
to 6 pounds of bran, or a J to J a pound of bicarbonate 
of soda, or an ounce of nitromuriatic acid, just before 
going to bed ; then drying the skin by wrapping in a 
warm sheet and patting the skin dry; then smearing the 
skin with a film of vaseline and dredging over this corn- 
starch powder, will often give him a good night's rest. 

Prognosis. The vast majority of cases of urticaria 
recover in a few hours or days. The chronic cases often 
are most obstinate, but unless some severe nerve lesion is 
at the bottom of the case, they can be cured by patient 
and persevering effort. When occurring in the course of 
pregnancy, premature delivery may have to be induced 
to relieve the woman of her suffering. 

Urticaria Pigmentosa. Synonym ; Xanthelasmoidea, 
XJ. perstans pigmentosa, 



URTICARIA PIGMENTOSA. 689 

Symptoms. This is not an ordinary urticaria, that, on 
account of its chronic course and the scratching to which 
it has been subjected, leaves more or less pigmentation of 
the skin. Such a condition of things is not infrequently 
seen. Urticaria pigmentosa begins within the first six 
months of life by an eruption of wheals or tubercles, which 
at first are about the size of a split pea, and of a brownish 
or yellowish-red color, with a pink areola. Later they 
may increase in size, or several may coalesce to form a 
large one, and assume a yellow or buff color. These 
wheals appear in crops, and run a very chronic course, 
each one persisting for weeks or months. Then they 
shrink, become softened, and disappear, leaving brownish 
pigmentation. As the course is chronic, we will find on 
the patient wheals or tubercles of red or yellow color, of 
various sizes, some hard and tense, some soft and wrinkled, 
and brown stains of the skin. Ordinary urticarial evanes- 
cent wheals will sometimes be found, and rubbing of the 
•apparently stationary tubercles will cause some of them 
to enlarge. The wheals are most often located on the 
trunk and neck ; then on the limbs, face, and head ; but 
they may appear on any part of the body surface as well 
as on the mucous membranes of the mouth and pharynx. 
Itching is usually present, but may be absent. After a 
number of years the wheals will no longer come out, and 
recovery is generally complete at about the age of puberty, 
though the disease may last much longer than that. Mor- 
row 1 has reported one case of over twenty years' duration. 
The majority of the cases, according to Crocker, occur in 
boys. We know no cause for the disease. 

Histologically, the characteristic feature, beside the 
oedema and deposit of pigment in the epidermis, is the 
cellular infiltration of the upper derma composed chiefly 
of mast cells. In this disease, even in the healthy skin, 
the number of mast cells is remarkably increased. Thus 
far treatment has been in vain. It is essentially the same 
as in chronic urticaria. One case was cured by Torok 
1 Journ. Cutan. and Gen.-Urin. Dis., 1895, viii., 445. 
44 



G90 DISEASES OF THE SKIN. 

and Schein 1 by the #-rays, used to the production of a 
dermatitis. 

Vaccinal Eruptions. The eruptions that accompany or 
follow vaccination may be local, starting from the point of 
inoculation ; or general, and due to the absorption of the 
virus, which in some subjects acts as do medicinal sub- 
stances in other people. The majority of them are due 
not to any bad quality of the virus, but either to some 
accidental infection or to idiosyncrasy. Sometimes an 
ulcer will form at the site of the vaccination ; or starting 
from this point we may have a dermatitis, cellulitis, 
lymphangitis, erysipelas, abscess, or furuncle. At times 
exuberant granulations, or what is called an infective 
granuloma, may develop upon the seat of the vaccination. 
An outbreak of impetigo contagiosa may originate from 
inoculation, the pus of the sore becoming transferred to 
other parts by the finger nails ; or an eczema or psoriasis 
may be set up by the irritation of the sore, just as they 
may follow other affections of the skin. 

General eruptions usually appear, according to Harda- 
way, after the ninth or tenth day of vaccinia, and assume 
an erythematous, papular, or papulo-vesicular character. 
The roseola vaccina of Hebra is an erythematous eruption 
of macular character, commencing usually upon the arms, 
and sometimes spreading over the whole body. It is ac- 
companied in some cases with slight rise of temperature 
for a few hours. It disappears and leaves no trace. 

We may also encounter erythema multiforme and urti- 
caria complicating vaccination. It is possible that a bul- 
lous eruption may occur, but this is very rare. Syphilis 
also may be inoculated in arm-to-arm vaccination. Gan- 
grene may occur in the sore and other accidents. All of 
these are rare. 

Varicella, or Chicken-pox, is an eruptive fever of mild 
grade, with an incubative period of two weeks. It is 
characterized by an outbreak of a greater or less number 

i Wien. med. Woch., 1902, liii., 847. 



VARIOLA. 691 

of transient red papules and clear vesicles, of pinhead to 
pea size, and varying shape, that come out in crops. Later 
they may become pustules. A long vesicle is very char- 
acteristic of this eruption, as is the location of the vesicle 
or pustule to one side of the areola. The eruption is usu- 
ally scanty. Umbilication occurs in some of the vesicles. 
The vesicle can be easily ruptured. There is usually only 
slight constitutional disturbance. The mucous membranes 
may be involved. In the early stages there is possi- 
bility of taking the disease for variola. It is differen- 
tiated from it by the mildness of its symptoms, the finding 
of lesions in all stages, the ease with which the vesicles 
may be ruptured, the infrequence of umbilication and the 
rapid course it runs. Treatment is purely expectant. 

Varicella Gangrenosa. See Dermatitis gangrenosa in- 
fantum. 

Variola, or Smallpox, is an acute contagious fever with 
an incubative period of about two weeks. It is charac- 
terized by very severe prodromal symptoms, such as 
headache and intense pain in the back and legs, and the 
appearance, usually on the third day, of an eruption of 
minute red spots that soon change into small, round, hard, 
shotty papules. The eruption is first seen on the face 
about the forehead and mouth and on the neck and wrists. 
In about twenty-four hours after its first appearance ves- 
icles form upon the papules, and attain their full devel- 
opment by about their fifth day. They then are umbili- 
cated, are located upon a hard base, and have a well- 
marked areola. Now they change into pustules, and a 
well-marked secondary fever attends the change. After 
about four or five days the pustules dry up into crusts, 
and afterward these fall, leaving pitted cicatrices in many 
places. The mucous membranes are commonly involved. 
In varioloid, modified smallpox, the constitutional symp- 
toms as well as the eruption are of much milder grade. 

Diagnosis. Variola bears a resemblance to the pus- 
tular syphilide ; for the differential diagnosis, see the 



692 DISEASES OF THE SKIN. 

" pustular syphilide." Acue and pustular eczema both 
have lesious resembliug those of variola, but are limited 
to certaiu regions, and are not general eruptions. Vari- 
cella and papular erythema have been mistaken for vari- 
ola. In its earlier stages the diagnosis of variola is very 
difficult. In pronounced cases, on the other hand, the 
diagnosis is easy. For the diagnosis from varicella see 
varicella. 

Varus. See Acne. 

Vegetation dermique. ^ 

Vegetations. V See Verruca. 

Venereal Wart. J 

Veld Sore. According to Crocker, this is a disease met 
with in South Africa. The sores occur most often on the 
hands and forearms, feet, and legs. They begin as itch- 
ing pinhead papules, vesicles, or pustules, which rapidly 
increase in size. They rupture readily and form painful 
dirty-looking sores, covered with a crust exuding pus and 
serum. There is often a lymphangitis and enlargement 
of the lymph glands. Sometimes it may take the form 
of a huge flat pustule covering the whole of the back of 
the hand. Cultures show a coccus resembling staphylo- 
coccus aureus. It may be only a form of tropical impe- 
tigo contagiosa or ecthyma. Horseflies are accused as 
being the distributing agent. The treatment is by means 
of antiseptic dressings. 

Verbrennung. See Dermatitis ambustionis. 

Verruca. Synonyms : (Fr.) Verrue ; (Ger.) Warze ; 
Wart. 

These exceedingly common papillary outgrowths assume 
various appearances, to which descriptive names have 
been given. Thus we have verruca vulgaris, or the wart 
so often seen on the hands of children and young people. 
These vary in size from that of a hemp-seed to that of a 
split-pea, or larger where two or more become aggregated. 
They are sessile, hard, conical, with flattened tops. They 



VERRUCA. 



693 



may be smooth, or uneven, showing their papillary for- 
mation. They may be of the color of the skin, or some 
shade of yellow, brown, black, or green. There may be 
a number of them, and they may be isolated or aggre- 
gated. They may occur elsewhere than on the hands. 




Verruca vulgaris. (By the courtesy of Dr. S. Dana Hubbard). 

One variety occurs on the soles of the feet. They look 
like callosities. They are often painful. When the hard 
calloused skin is shaved off the warty character of the 
growth is disclosed. Verruca digitata is a wart in which 
the papillae are separated distinctly from each other. 



694 DISEASES OF THE SKIN. 

These occur in groups, aud are often seen on the scalp. 
Verruca jiliformis is a wart in which the papillse are not 
only distinct, but fine, almost thread-like. Each papil- 
lary outgrowth stands by itself. These are soft to the 
touch, and occur on the face, eyelids, and neck. Ver- 
ruca plana is a flat wart, but slightly elevated, and vary- 
ing in size from that of a pinhead to a half-inch in dia- 
meter. These sometimes occur in large numbers. In 
young people they occur upon the face and backs of the 
hands, and may or may not be pigmented. In old people 
they occur on the trunk and arms and are pigmented, 
and are called verruca senilis or seborrhceal warts. Ver- 
ruca acuminata, also called condyloma acuminata, vegeta- 
tion dermique, spitzen warzen, and venereal or moist wart, 
is met with in the anal and genital regions of both sexes, 
as also in the axillse, under the hanging breasts, in the 
umbilicus, and between the toes. These are vascular, 
sessile or pedunculated, and composed of a great number 
of closely aggregated projections of various shapes. On 
exposed situations they are dry and of the color of the 
skin ; while in locations that are moist — that is, between 
the skin-folds — they are covered with a w T hitish puriform 
secretion, and, unless kept very clean, they emit an offen- 
sive odor. They sometimes attain to an immense size. 

Etiology. We do not know the cause of warts. 
They are contagious, or auto-inoculable at least, and par- 
asites have been isolated and declared to be the morbific 
agents. They have been produced by inoculation. They 
occur more frequently in the young than in the old, and 
may be congenital. Venereal warts are traceable to irri- 
tating discharges, but not by any means always to a 
gonorrhoea. They are undoubtedly contagious. 

Pathology. Warts concern the rete mostly, being 
markedly downward and upward growths of its cells. The 
papillse beneath the wart are flattened. The corneous layer 
of the skin is hypertrophied, but less compact than normal. 
Verruca? acuminata? differ from other warts in the absence 
of any anomalies of keratinization, and in the excessive 



VJEMRUOA. 695 

development of the rete, marked papillary enlargement 
and abundant vascular supply. 

Treatment. The treatment of most all warts is prompt 
and efficient by means of the curette, scraping them off 
while the skin is slightly stretched. If there is any doubt 
about their returning, their bases may be touched with 
iodine or nitric acid. Geuerally simple scraping is suffi- 
cient. The wart often is thus turned out of the skin entire, 
like a pea from a pod. No scar is left, because the corium 
is not wounded. Electrolysis may be used. The digitate 
and filiform warts may be suipped off with the scissors. 
If operative interference is refused, the warts may be re- 
moved by painting with tincture of iodine ; or a saturated 
solution of salicylic acid; or a 20 per cent, solution 
ofresorcin; tincture of thuja; or nitric or glacial acetic 
acid. G. W. Fitz 1 says that painting them daily with a 
10 per cent, solution of chrysarobin in traumaticin, after 
rubbing them down with fine sandpaper, will remove them 
in a week or so. In the country children's warts are re- 
movable in some cases by the application of the juice of 
the common milk-weed. Chromic acid is a powerful 
caustic. Caustic potash is not a safe agent to use, unless 
care is had to limit its action by a ring of wax about the 
wart. The galvano-cautery may also be employed, as well 
as x-rays. Sparking with the high-frequency current is 
also a good method of treatment. 

Venereal warts may be removed by keeping them clean 
and dry, and painting them with liq. plumbi subacetatis, 
or a solution of the perchloride or persulphate of iron ; or 
dusting them with salicylic acid and starch, or with boric 
acid. 

It is said that warts may be removed by internal treat- 
ment. Sulphate of magnesia, 2 to 3 grains to a child 
and J a drachm to an adult, three times a day, is one 
remedy. Besnier has tried this method in a number of 
cases with absolute unsuccess. Tincture of thuja occi- 
dentals is said to be efficacious. Crocker thinks he has 
1 Boston Med. and Surg. Journ., 1899, cxl., No. 26. 



696 DISEASES OF THE SKIN. 

seen cures effected with full doses of nitromuriatic acid, 
while others advocate arsenic. J. B. Cooper * claims to 
cure warts in from four to six weeks by giving a wine 
glass of lime water in a little milk after the noon day 
meal. C. Watson 2 has cured a case of multiple warts 
by giving a \ ounce of castor oil twice during the first 
week, and once a week afterward. I have tried this with- 
out success. 

Warts very often disappear of themselves and no one 
has ever seen them fall. 

Verruca Necrogenica. See Tuberculosis verrucosa cutis. 
Verrue. See Verruca. 

Verrue Telangiectasique. See Angiokeratoma. 
Verruga, Endemic. See Yaws. 

Verruga Peruana. This disease is said to occur in the 
narrow, hot valleys of Peru. It begins as a fever resem- 
bling malaria, accompanied by anaemia, pains in the joints, 
neuralgia, and swelling of the liver and spleen. The 
patient may die in this stage. If he survives, the warts 
follow the fever. They may appear suddenly without the 
prodromal fever. They may be miliary in size, and rosy 
and translucent ; or larger, forming dull horny papules ; or 
nodular in size, when they may be complicated with fur- 
uncles. They are scattered over the body. They may 
undergo spontaneous involution. A special bacillus is 
supposed to ba the cause of the disease. They are to be 
scraped off with a curette, and the patient is to be re- 
moved from the endemic area and given large doses of 
the chloride of iron. 

Vibices. See Purpura. 

Vitiligo. Synonyms : Leucoderma ; Leucasmus ; Leu- 
copathia ; A chroma ; Piebald skin. 

An acquired loss of pigment of the skin characterized 

i Brit. Med. Journ., 1905, ii., 441. 

2 Brit. Journ. Dermat., 1903, xv., 178. 



VITILIGO. 



697 



by the formation of symmetrical white patches with con- 
vex borders surrounded by an area of hyper-pigmentation. 
Symptoms. This is an acquired anomaly of pigmen- 
tation, the opposite to chloasma. It is akin to albinismus, 
only that the latter is a congenital condition. It consists 
in the disappearance of the pigment of the skin in circum- 
scribed round or oval patches so that white areas are 

Fig. 97. 




Leucoderma. (By the courtesy of Dr. S. Dana Htjbbarb.) 



formed. At the same time there is an accumulation of 
pigment around the areas, so that there is at once a process 
of apigmentation and of hyper-pigmentation. The size of 
the patches varies greatly. They may be no larger than a 
ten-cent piece or of immense size. The disease most com- 
monly begins upon the neck, face, or backs of the hands, 
but may begin anywhere. It is chronic. It may progress 
so as eventually to involve nearly the whole body ; or it 



698 



Diseases oi the skm. 



may become stationary ; or, in rare cases, the skin may 
become pigmented again. It is a symmetrical disease in 




Leucoderma. (After Hyde.) 



nearly all cases. The general health is unaffected, and 
there is no change in the sensibility of the patches. In 
some cases the white parts are unusually sensitive to expos- 



VITILIGO. 699 

lire to the sun. When the scalp or hairy regions are 
affected the hair turns white. The disease is most evident 
in the summer on account of the increased pigmentation 
that normally occurs in the sound skin at this season. 

Etiology. The cause of the disease is obscure. All 
we can now say is that it is probably a disturbance of in- 
nervation. It is uncommon for it to occur before the tenth 
year of life, though it may do so. Adults are most fre- 
quently affected. Both sexes are subject to it. It is more 
common in the warm than in the cold countries, and is 
particularly common in negroes. Exposure to the sun 
and cold seems to be an excitant in some cases. It has fol- 
lowed typhoid fever, scarlatina, and malarial fever. Wood x 
says that when mulattoes contract syphilis they become 
several shades lighter all over the body. Symptomatically 
it is seen with morphoea, Addison's disease, and alopecia 
areata. There is also a syphilitic vitiligo. I have 
had one case in a man of eighteen years, who began to 
smoke tobacco when he was six years of age, and had con- 
tinued to do so. He seemed to be in the best of health. 

Diagnosis. There is little difficulty in diaguosis, as 
there is no other disease in which the only symptom is a 
loss of pigment with a surrounding pigmentation. In mor- 
phoea the patch may be raised, and the skin is changed in 
texture, and there is apt to be a little ring about it. In 
chloasma the patch itself is dark with a convex border, 
while in vitiligo the border of the pigmentation is 
concave. The concave border of the pigmentation will 
also distinguish the disease from ehromophytosis, which 
is also scaly. The normal sensation of the patches dis- 
tinguishes them from leprosy, in which the patches are 
anaesthetic. 

Treatment. Unfortunately there is hardly anything 
that can be done in the way of treatment. Galvanism or 
faradism may be tried, and nerve tonics given. We must 
content ourselves with making the patches less evident 
by removing the pigment from about them by the means 
1 Journ. Cutan. and Ven. Dis., 1883, i., 274. 



700 DISEASES OF THE SKIN. 

given under Chloasma. Or we can stain the patches so 
that they shall be less white, as by the use of walnut 
juice. Besnier and Doyon believe that they have cured 
cases in young subjects by the prolonged use of bromide 
of potassium internally, and saline or bromo-iodide baths 
externally, with or without injections of pilocarpine. 

Vitiligo Capitis. See Alopecia areata. 
Vitiligoidea. See Leucoderma. 

w " i See Verruca. 

Warzenkrebs. See Carcinoma. 
Warzenmal. See Nsevus verrucosus. 

Washleather Skin is that condition of the skin in which 
certain metals, specially silver, mark it with a black line. 
It occurs, as a rule, in patients suffering from diseases 
which directly or indirectly affect either the trophic or the 
sensory nerves, such as renal disease, phthisis, erysipelas, 
and hemiplegia. It sometimes precedes the occurrence 
of bed-sores. 

Weichselzopf. See Plica. 
Wen. See Sebaceous cyst. 
Whelk, See Acne. 
Xanthelasma. See Xanthoma. 

Xanthoerythrodermia Perstans of Crocker is probably 
the same as Parakeratosa variegata. 

Xanthoma. Synonyms : Xanthelasma ; Vitiligoidea ; 
Molluscum cholesterique ; Fibroma lipomatodes. 

A peculiar disease of the skin characterized by the ap- 
pearance of discrete patches, or tubercles, of chamois or 
lemon -yellow color. 

Symptoms. Xanthoma may assume one of two forms : 
Xanthoma planum or Xanthoma tuberosum seu tuberculatum. 
In the former we meet with flat, chamois leather-like, or 
lemon-yellow plates that are either slightly raised above 
the level of the skin or not at all raised. Exceptionally 



XANTHOMA. 701 

they may be dark yellow, whitish or creamy, or deep 
brown. They vary in size from an eighth of an inch to 
an inch in their long diameter, feel soft and smooth to 
the touch, and when pinched between the fingers no infil- 
tration of the skin is perceptible. They are irregular in 
shape, tending to form elongated figures. When in patches, 
they feel almost velvety, and when examined with a lens 
they often are seen to consist of an aggregation of small 
granules, many of which have a central pinkish punctual. 

Xanthoma tuberosum exhibits lesions of the same color 
as does the plain variety, or they may be reddish yellow, 
but they are raised above the skin and may attain to a 
large size. They are soft, smooth, round or oval, with 
telangiectases over them when small. "When large, they 
are firmer and more irregular in shape, being made up by 
aggregation of a number of smaller tubercles. Xanthoma 
multiplex is the name applied to cases in which both varie- 
ties are present. In all forms, unless there is jaundice, 
the skin between and about the lesions is normal in color. 
Most cases give rise to no subjective symptoms, but there 
may be some itching or burning. If the disease occur 
upon the palms or knees, it may cause discomfort or even 
pain on kneeling or handling objects. 

The favorite site of xanthoma planum is in the upper 
eyelid, where they are not infrequently seen. There they 
commence at the inner canthus, most often of the left eye, 
and spread in a semicircle about the eye, while shortly 
afterward a similar growth begins on the right upper eye- 
lid. They may be found also on the lower lid. Next 
in point of frequency to the eyelids, they occur upon 
the flexures of the joints and upon mucous membranes. 
Xanthoma tuberosum is most frequently seen upon the 
knees, elbows, knuckles, and other points of pressure, the 
trunk being not so much affected. Symmetry is generally 
observed. Xanthoma multiplex is often very widely 
distributed. Sometimes the lesions run in streaks, or, as 
are arranged like a zoster. 
J St. Louis Courier of Med., October, 1884. 



702 DISEASES OF THE SKIN. 

Under the name of Pseudo-xanthom elastique E. Bodin 1 
has described an eruption of pinhead-sized, oval or round, 
pale-yellow lesions that occurred in symmetrical patches, 
about which were scattered single lesions. The surface 
of the patches was smooth or slightly granular. They 
occurred on the lower part of the abdomen, clavicular 
region, anterior wall of axillae, inside of arm, forearm, 
and thighs. 

The skin in xanthoma is not alone affected. Xantho- 
matous bodies are found in the liver, mucous membranes, 
and tendons. The disease is progressive for a time, and 
then may remain stationary for years, or may undergo 
spontaneous resolution. 

Etiology. Xanthoma occurs much more frequently 
in adults than in children, and that form that occurs in 
the eyelids is much more common in women than in men. 
Several cases may be seen in the same family, and the 
disease is sometimes hereditary. But we really do not 
know as yet what is the cause of the disease, though vari- 
ous theories have been advanced. Crocker states that 
four-fifths of the cases of xanthoma multiplex occurring 
after puberty are associated with chronic jaundice. Hepa- 
tic diseases ; diabetes ; diathetic conditious of various 
kinds ; migraine ; embryonic cells left in the skin — each 
have been found in connection with one or many cases. 
Hardaway may not be wrong in his idea that it is a dia- 
thetic disease, and that when it occurs with jaundice it is 
because the same tubercles have been deposited in the 
liver as in the skin, and the jaundice is secondary to 
them. 

Pathology. It is a connective-tissue new growth 
containing an abundance of fat. Between the connec- 
tive-tissue bundles the so-called " xanthoma cells " are 
found. The color of the lesions is due to fat-globules. 
(Heitzmann.) S. Pollitzer 2 believes that xanthoma pal- 
pebrarum is due to the degeneration of embryonically 

i Ann. de derm, et de syph., 1900, i., 1073. 
2 New York Med. Journ., 1899, lxx., 73. 



XANTHOMA. 703 

misplaced muscle fibres. Crocker does not accept this, 
but states that he considers " inflammation as the pri- 
mary feature, and the xanthoma cells and connective- 
tissue growth secondary, and the whole process of toxemic 
origin." 

Diagnosis. The diagnosis of this unique disease is 
made by the occurrence of chamois-leather-colored soft 
plates or tubercles, such as occur in no other disease. 
31 ilium may bear some slight resemblance to xanthoma-, 
but it is hard and firm, not soft and velvety, and white, 
not yellow. It is easily squeezed out after a prick through 
the skin over it, an impossibility in xanthoma. 

Treatment. In the way of treatment we have no 
sure resource save the knife and electrolysis. The latter 
is preferable. As in the operation for removal of super- 
fluous hair, the fine steel broach attached to the negative 
pole of the galvanic battery is used, and it is passed un- 
derneath the growth from side to side. A series of tracks 
under the growth and paralled to each other are made, 
the current always being completed after the needle is 
in position and broken before the needle is removed. 
A current of 2 or 3 milliamperes should be used. 
Besnier 1 reports good results from the administration of 
j)hosphorus in cod-liver oil, giving 1 milligramme per 
day, and increasing the dose each day by a J of a milli- 
gramme until 3 milligrammes are taken. After fifteen 
days this is stopped and turpentine is given. Stern 2 tried 
this plan without success, but succeeded in removing 
patches of the disease from the eyelids by the use of a 10 
per cent, solution of corrosive sublimate in collodion. 
Shepherd, of Montreal, saw one case recover after an 
operation for biliary calculi ; and McGuire removed one 
with monochloracetic acid. Stelwagon commends tri- 
chloracetic acid, at first diluted, applied cautiously to a 
small part at a time, the reaction being controlled by 



1 Journ. de Med. et de Chir., April, 1866. 

2 Berlin, klin. Wochenschr. , 1889, xxx., 3 



704 DISEASES OF THE SKIN. 

vaselin or cold cream. Salicylic acid in collodion, 10 or 
15 per cent., may be used. 

Prognosis. The growths when fully formed remain 
stationary, showing no tendency to change in any way. 
Exceptionally they may disappear of themselves. Treat- 
ment is most often disappointing, as when apparently 
. removed they tend to return. 

• Xanthoma Diabeticorum. Besides the xanthoma just 
described, there is another form which is regarded as a 
distinct affection, and called Xanthoma diabeticorum. 

Symptoms. It consists in the eruption of round, firm, 
dull-red papules, on top of many of which is a yellow or 
yellowish-white head, and over many there are dilated 
vessels. Some papules may be pierced by hairs. They 
may be discrete or grouped. They may itch or pain, 
and are located especially on the buttock, elbows, and 
knees, but may occur anywhere. The eruption appears 
suddenly, and after months or years may disappear 
quickly. Relapses may occur. 

Etiology As the name indicates, in most cases dia- 
betes is found, but it occurs without diabetes at times. 

Pathology. The disease process appears to be of the 
same nature as ordinary nodular xanthoma, but with more 
inflammatory phenomena and less connective -tissue 
growth. (Crocker.) 

Diagnosis. It differs from ordinary xanthoma in its 
more sudden development ; in disappearing sooner or later, 
perhaps to recur ; in the hardness of its lesions, which 
are never macular ; in the frecpient absence of a yellow 
color ; in the presence of a certain amount of inflamma- 
tion ; in the absence of jaundice and presence of diabetes 
mellitus ; in its more pruriginous character ; in avoiding 
the eyelids ; and in having its lesions about the mouths 
of the hair follicles. In fact, it resembles ordinary xan- 
thoma mostly in its location upon the elbows, knees, and 
other points of pressure, and in the general configuration 
of the lesions. 



YAWS. 705 

Treatment should be directed to the diabetes, which 
is at the foundation of the disease, and to the allaying of 
the itching. 

Xeroderma. See Ichthyosis. 

Xeroderma Pigmentosum. See Atrophoderma pigmen- 
tosum. 

Yaws. 1 Synonyms : Framboesia ; Pian ; Parangi ; 
Verruga; Granuloma tropicum. 

This is a disease that occurs only in tropical countries. 
The stage of incubation lasts from two to eight weeks up 
to three or four months, and is without special symptoms. 
At the end of this stage the initial lesion appears. It is 
a pinhead-sized papule that becomes pustular, and then 
changes into an ulcer with perpendicular edges. The 
occurrence of the initial lesion is often unobserved, and 
some authorities deny its existence. The stage of inva- 
sion, with more or less well-marked fever and rheumatic 
pain, which abate before the eruption appears, lasts one 
or two weeks. The eruption is preceded by enlargement 
and tenderness of the lymphatic glands, and consists of 
pinhead- to lentil-sized, slightly elevated papules on a 
broad base. The papules enlarge; the epidermis splits 
and curls off from their centres, and exposes a yellowish 
point which develops into a flat, moist, red or pink tumor, 
looking not unlike a raspberry. These tumors range in 
size from that of a split pea to that of a nut, are round or 
oval, discrete or coalesced into large irregular masses. 
The surface of the tumor is covered with a thin, yellowish, 
foul-smelling discharge, that dries into a crust, which may 
ultimately assume a rupia-form. In the mouth and in 
moist situations no crusts form, and the tumor will resemble 
mucous patches. They reach their full development in 
from two to four weeks, remain stationary for months, 
and then dry up and fall off, leaving a stain on the skin, 
that eventually disappears. They may break down and 
ulcerate, involving both the adjacent soft parts and the 

1 This account is condensed from Crocker, 
45 



706 DISEASES OF THE SKIN. 

bones. The tumors are not tender. The disease tends 
to recovery, but is subject to relapses. It is contagious, 
and one attack is protective to a certain extent. Death 
occurs in bad cases. It is supposed to be due to a specific 
micrococcus. 

Diagnosis. The diagnosis is from syphilis. It dif- 
fers from it in attacking children specially, in having no 
initial lesion, in its lesions not showing polymorphism, in 
absence of lymphatic nodes, and in being itchy. 

Treatment. The treatment is the same as in syphilis 
— that is, by mercury and iodide of potassium, and care 
of the patient's general condition as to hygiene and sur- 
roundings. Locally, disinfectant and mercurial applica- 
tions should be used. 

Zaraath. See Lepra. 
Zona. See Zoster. 

Zoster. Synonyms : Zona ; Herpes zoster ; Ignis sacer ; 
(Ger.) Feuergtirtel, Giirtelkrankheit ; Shingles. 

An acute disease of the skin characterized by a unilat- 
eral eruption of groups of vesicles upon reddened bases 
scattered along the course of certain nerves. 

Symptoms. Zoster, like psoriasis, presents such 
marked lesions that once seen it is readily recognized 
when seen again. It occurs in the form of groups of 
vesicles seated upon red bases, and arranged along the 
course of nerves upon which there are ganglia. (Fig. 
99.) The vesicles are at first filled with serum that af- 
terward may become cloudy. They do not tend to break 
down of themselves, but are frequently ruptured by ac- 
cident. The size of the groups varies greatly. There may 
be but a few vesicles or a large number of them closely 
crowded together. Sometimes a group is no larger than a 
three-cent piece, and sometimes it is several inches in 
its longest diameter. Sometimes the vesicles may run 
together and form blebs. The shape of the groups is 
always irregular. There may be but two or three groups 
or a score of them. In nearly all cases the disease is 



ZOSTER. 707 

unilateral, though it is not uncommon for one or two 
groups to be found close to the middle line, on the side 
opposite to the site of the disease, and cases of double 
zoster occur, though very rarely and never on the same 
level. All the groups do not come out at once, but, as 
it were, by a series of outbreaks, the earliest ones to ap- 
pear usually being those nearest the point of exit of the 
nerve. The eruption is usually at its height in a week, 
the vesicles drying up, forming a crust and falling off, 
leaving a red mark that soon fades. The whole duration 
of the disease is from ten days to three or four weeks. 

In many, if not most, cases the patient experiences 
neuralgic pain in the nerve along whose course the erup- 
tion is about to appear. This is sometimes wanting, and 
generally lessens or disappears when the eruption appears. 
Sometimes the pain is severe during the duration of the 
eruption, and after it is gone. Tender points may often 
be found over the points of exit of the nerves, like those 
found in neuralgia. In some patients there will be fever 
before the outbreak of the vesicles or the successive 
appearance of new groups. The vesicular stage is preceded 
by an erythemato-papular stage. V ery rarely some of the 
groups may abort at this stage. Exceptionally, zoster 
may occur on both sides of the body. In nearly all cases 
the disease does not recur. Exceptionally a patient may 
have several attacks of the disease. 

Most cases of zoster occur upon the trunk, and, it is 
said, especially on the right side. It also occurs upon 
the face, on branches of the fifth nerve, when it may in- 
volve the eye and produce blindness by destructive 
ulceration of the cornea. The neck may be affected, and 
with it the arm. The leg, too, may suffer. Generally the 
eruption does not reach further down than the elbow and 
knee, though it may occupy the forearm and hand, leg and 
foot. In rare instances the tongue and pharynx may be 
affected. Various names are used to designate the location 
of the eruption, such as zoster frontalis, ophthalmicus, 
cervicalis, intercostalis, genito-cruralis, and the like. 



708 DISEASES OF THE SKIN. 

In rare cases hemorrhage may occur into the vesicles, 
or they may be purulent from the start, or they may 
ulcerate, or become gangrenous. The neuralgia may con- 
tinue in old or debilitated subjects in so severe a manner 
as to threaten the exhaustion of the patient from pain and 
loss of sleep. Or pruritus, hyperesthesia, or anesthesia 
may be left for some time after the disappearance of the 
eruption. Or paralysis of motion may follow the attack, 
as well as atrophy of muscles. Scars will follow the 
disease if ulceration has occurred. 

Etiology. Zoster occurs more often in children than 
in adults. Sex seems to have little influence. It follows 



Fig 




Zoster of arm. 

upon injuries to nerves in some cases, and has been as- 
sociated with caries of the ribs. It has been known to 
occur while the patient was taking arsenic. It occurs 
frequently in the damp, cold weather of the spring and 
autumn, so much so as to give rise to epidemics. Indeed, 
some regard the disease as infectious on account of the 
epidemic character it sometimes has. Some cases seem 
to arise from peripheral irritation of cutaneous nerves. 
A descending peripheral neuritis of the spinal ganglion is 
regarded by Crocker as the condition most frequently 
associated with the disease. He also regards the disease 
as of toxic origin. In a great number of cases disease of 



ZOSTER. 709 

the ganglia upon the posterior roots of the spinal nerves 
has been found post mortem. When the fifth nerve is 
affected, it is the Gasserian ganglion that is diseased. 
Zoster may arise from injury, as a wound of a nerve- 
trunk, and then we may have an ascending zoster, the 
first group being nearest the point of injury. 

Pathology. The zoster vesicle begins in the lower 
rete layer ; the epithelial cells enlarge, assume vari- 
ous shapes, probably from pressure, and finally liquefy. 
Even in the formed vesicle some of the distended 
cells may be seen adherent to the floor. The roof is 
formed by the corneous layer. Besides serum and the 
debris of epithelial cells, the vesicles may contain few 
or many pus cells, and even in the hemorrhagic form, 
some red-blood corpuscles. There are secondary inflam- 
matory changes in the rete and in the derma. 

J. F. Schamberg 1 says that on the posterior roots 
of the spinal nerves are found : 1. Acute inflammation 
with exudation of small, red, deeply staining cells. 2. 
Extravasation of blood. 3. Destruction of ganglion cells 
and fibres, and 4. Inflammation of the sheath of the 
ganglion. 

Diagnosis. Zoster in most cases is readily recogniz- 
able. It differs from eczema in having larger vesicles 
that do not tend to rupture; in its patchy character, the 
patches being located along certain nerve-trunks ; in the 
neuralgia that accompanies it ; and in the definite course 
that it runs. Herpes facialis or progenitalis sometimes 
resembles zoster quite closely, but in them there will 
often be a history of previous attacks ; they will not 
occur so markedly as groups of vesicles upon one side 
alone ; and they will not be preceded by the same amount 
of neuralgia. By some authorities herpes and zoster are 
considered to be the same disease. 

Treatment. The most important part of the treat- 
ment of zoster is to prevent the breaking of the vesicles, 
and the possible ulceration that would follow and leave 
1 Jour. Amer. Med. Assn., 1907, xlviii., 746. 



710 DISEASES OF THE SEW. 

scars. To this end we should avoid ointments and use 
dusting powders, such as oxide of zinc, bismuth, starch, 
guaiacol, 5 per cent, with starch powder, or, what is 
better, we should paint the vesicles with flexible collodion 
with or without morphine, which sometimes seems to abort 
the formation of vesicles, with a 50 per cent, aqueous 
solution of ichthyol. It is also advisable to cover the 
eruption with a soft linen bandage to prevent rubbing. 
If the vesicles have become broken and ulceration has 
ensued, then we have to treat the ulcers on surgical 
principles. 

To relieve the pain of zoster the galvanic current gives 
the best results, one sponge electrode being placed over 
the spine, and a steel roller electrode attached to the other 
pole and passed around the groups for ten or fifteen 
minutes once or twice a day. A current-strength of 2 
or 3 milliamperes may be used, and, if it can be done, 
the last application should be made just before going to 
bed. Other means are hypodermics of morphine ; blister- 
ing or dry cups over the root of the nerve ; guaiacol as 
mentioned above, and the use of the menthol cone or oil 
of peppermint. Phosphide of zinc, J of a grain every 
three hours, is thought by some to relieve the pain and 
limit the eruption. For the persistent neuraligia that at 
times follows these cases, arsenic, or strychnine, iron, 
quinine, cod-liver oil, and a good nutritious diet are 
necessary. Opium or other analgesic may have to be 
given to allay pain and procure sleep. 

Prognosis. Most cases of zoster run a favorable 
course and get well of themselves. It is only in old or 
debilitated people that we need fear any serious results. 
There is always the possibility of the occurrence of ulcer- 
ation and gangrene, though it is not to be expected in the 
vast majority of cases. The popular opinion that if 
zoster occurs on both sides at once and forms a girdle the 
patient will die, has no foundation in fact, as such an 
occurrence is unknown. 



APPENDIX. 



The following formulae are given as guides in the preparation of pre- 
scriptions for the treatment of skin diseases. Many, if not all of them, 
have been well tried and their value proved. 

A. BATHS. 

Simple Water Baths: 

Cold 40°- 65° F. 

Cool 65°- 75° F. 

Tepid 85 c - 95° F. 

Warm 95°-100° F. 

Hot 100°-110° F. 

Wet Pack. Wrap patient in a wet sheet and roll up in a blanket. 
After twenty to thirty minutes remove the pack, rub dry, and anoint 
with oil or ointment. Useful to remove the scales in psoriasis and to 
diminish hyperemia. 

Medicated Baths. To an ordinary bath-tubful, say thirty gallons 
of water, add for 

Bran bath 2 to 6 pounds bran. 

Potato-starch bath . 1 pound starch. 

Gelatin bath . . . 1 to 3 pounds gelatin. 

Linseed " ... 1 pound linseed. 

Marshmallow bath . 4 pounds marshmallow. 

Size bath 2 to 4 pounds size. 

These baths are useful in erythematous, itchy, and scaly diseases. In 
using bran it should be tied up in cheese-cloth bags before being 
put in the water. 

For an alkaline bath add to bath, 

Bicarbonate of soda 2 to 10 ounces, or 

Carbonate of potassium .... 2 to 6 " or 

Borax 3 " 

These baths are useful in eczema, psoriasis, urticaria, prurigo, and 
pruritic diseases. 

For an acid bath add to bath, 

Nitric acid 1 ounce, or 

Muriatic acid 1 " 

Or may use of each . £ " 

Of use in chronic pruritic diseases. 

711 



712 APPENDIX. 

Iodine Bath: 

To bath. 

Iodine J to 1 drachm, 

Iodide of potassium, vel .... J ounce. 

Liquor potassse 1 to 2 ounces. 

Glycerin 2 " 

Useful in scrofulous and squamous diseases. 

Bromine Bath; 

To bath. 

Bromine 20 drops. 

Iodide of potassium 2 ounces. 

Same indications as iodine bath. 

To bath. 
Sulphuret of potassium 2 to 4 ounces. 

Used in scabies, chronic eczema, lichen, and psoriasis. 

Startin's Compound Sulphur Bath : 

To bath. 

Precipitated sulphur 2 ounces. 

Hyposulphite of soda 1 ounce. 

Water 1 pint. 

Same indications as the sulphuret of potassium bath. 

Mercurial Bath: 

To bath. 

Bichloride of mercury 3 drachms. 

Hydrochloric acid 1 drachm. 

Water 1 pint. 

Used in pityriasis rubra and the syphilides. 

B. FOR INTERNAL USE. 

1. Turpentine Emulsion: 

R. 01. terebinthinae, l^x-xxx ; 0.66-2 

01. limonis, ff\,ij ; 1 

Mucilag. acacise, £ss ; 16 

Aquae destil., ^ss ; 16 M. 

Sig. A teaspoonful three times a day immediately after meals. 
One quart of barley-water to be drunk during twenty-four 
hours. (Crocker.) 
Used in psoriasis, eczema, and hyperaemias. 



06-.2 



M. 

Sig. One drachm in water t. i. d. one hour after meals. (Taylor.) 



2. Mixed Treatment: 






a. R. Hydrarg. bichlor., 
Potass, iodid., 
Tinct. cinchon. co., 
Aquae destil., 


gr- j-iij ; 
giv-viij ; 
M"jss ; * 
gss; 


16-32 
112 

16 



APPENDIX. 



713 



R. Hydrarg. biniod., 
Ammon. iodid., 
Potass, iodid., 
Syr. aurant. cort., 
Tinct. aurant. cort., 
Aquse destil., 



ad 



gr. ss-ij 

3 ss ; 

|jss; 



8- 



2 

-32 

48 

4 

ad 100 



03-.13 



M. 



Sig. One-half ounce t. i. d. after meals. (Keyes. ) 



4-8 
ad 128 



06-.13 



M. 



c. R. Hydrarg. bichlor. vel "I ... 

Hydrarg. biniod., / & • J J 

Potass, iodid., 3J _ ij > 

Inf. gent. co. vel ) rl 5' • 

Syr. sarsaparillse co., / ^ ' 
Sig. One drachm t. i. d. after meals. 
These three are used in syphilis. 

3. R. Pil. hydrarg., 

Ferri sulphat. exsic, 

Ext. opii, gr. v ; 33 M. 

Div. in pil. No. xl. 
Sig. Onet. i. d. (Taylor.) 
Used in syphilis. Sulphate of quinine may be substituted for the iron. 

4. R. 01. gurjun., gj; 33133 

Liquor calcis, ^iij ; 100 [ M. 

Sig. One-half ounce twice a day. 
Used in leprosy. 

5. R. Tinct. cannabis indicse, 



gr. xl ; 


2 66 


gr. xx ; 


133 


gr. v ; 




33 



Pulv. tragacanth. co., 
Aquse destil., 
Used in pruritus and prurigo. 



TT^x-xxx 
gr. x ; 
ad lj ; 
(Bulkley.) 



0.66-2 
ad 32 



06 



M. 



6. 



Startin's Mixture: 

R. Magnesii sulphat., 3vj-xij ; 24-48 

Ferri sulphat., 3J ; 4 

Acid, sulphur, dil., ^ij ; 8 

Syr. pruni virgin., ^j ; 32 

Aqua? destil., ad^iv; ad 128 

Sig. One drachm t. i. d. after meals, through a tube, 
tive and tonic. 



M. 

As a laxa- 



Asiatic Pills: 
R. Acid, arsenosi, 

pip. nigrae, 



gr. xj ; 
Pulv. pip. nigrae, giss: 

Gummi acacise, gr. xxij ; 

Pulv. althae rad., gr. xxx ; 

Aquse destil., q. s. ; 

Div. in pil. No. c. 

Sig. One to three pills a day after meals 
Used in psoriasis. 



M. 



and increase to tolerance. 



14 APPENDIX. 




8. R. Hydrarg. chlor. mitis, gr. jss; 
Ferri lactatis, gr. iij ; 
Sacch. alb., gr. xv ; 1 


02 
04 


Ft. in pulv. No. x. 




Sig. One to four daily. (Monti.) 
Used in infantile syphilis. 





M. 



C. FOR EXTERNAL USE. 

a. Caustics. 

1. Cosine' 's Paste: 

R. Acid, arsenosi, g r - x > 

Hydrarg. sulphuret. rub., £ss ; 

Ungt. rosse vel "I ■? 

Sacch. alb., J 5SS; 

To destroy epithelioma or other new growths. 

2. Marsden's Paste: 



(66 



2 

16 



R. Pulv. acid, arsenosi, 
Pulv. ffummi acaciee, 



2 parts by weight. 
1 part " " 

Mix with a twenty per cent, solution of cocaine to form a paste 
just before using, and apply to not more than one square 
inch at a time. 

Same indications as Cosme's Paste. 



3. Bougard! s Paste : 

R. Wheat flour, \ 
Starch, J 

Arsenic, 

Cinnabar, \ 

Sal ammoniac, / 
Corrosive sublimate, 
Sol. chlor. of zinc @ 52 c 



aa 60 parts. 

1 part. 

aa 5 parts. 

% part. 
245 parts. 



M. 



Grind first six ingredients to a fine powder, then mix them in a 
mortar. Add solution of zinc chloride slowly stirring. Keep 
in earthen jar. May add cocaine up to 20 per cent, to allay 
pain. 

Sig. Apply accurately to part; keep on for thirty hours; follow 
with poultice. 



4. Depilatory Paste: 

R. Barii sulphid. 
Zinci oxidi, 



aa 3iij ; 



12 



M. 



Amyli, / 

Make into a paste with water and apply a thin coating for ten to 
fifteen minutes, then clean off and apply a bland ointment. 



APPENDIX. 



715 



5. Salicylic Acid (Crocker) : 

R. Glycerini, 5J ; 321 

Acid, salicyl., q. s. ; q. s.i M. 

Make of consistency of thick cream. To lessen painfulness of 
application may add 

Ac. carboliei vel \ . A 

Creosoti, J 3J » | 

Used to destroy warts, lupus, and epidermic thickenings. 



6. Vienna Paste: 
R. Calcis, \ 

Potassse, / aa P ,: 

Make into a paste with alcohol just before using. 
Used in lupus and scrofulides. 



,} 



7. Canquoin's Paste: 
R. Zinci chlor., 
Ammon. chlor. 
Pulv. amyli, 
Aquae destil., 
Make into a paste at time of using. 
Used to destroy lupus, epithelioma, and the like. 



q. s. 



aa 4 

6 
q. s. 



8. Middlesex Hospital Paste : 
R. Zinci chlor., "I 

Liq. opii sed., / 

Amyli, 

Aquae destil., 
Same indications as Canquoin's paste. 



aa ^iv ; aa 16 
3J SS I 6 

ii ; 32 



M. 



M. 



M. 



9. R. Zinci nitrat., 
Micae panis, 
Mix before using. 


1 part. 

2 parts. 




6. 
1. Belladonna Lotion: 


Lotions. 




R. Tinct, belladou., \ 
Glycerini, J 
Aquae destil., 
For erysipelas. (Piffard.) 


aa 1 part. 
8 parts. 




2. Bismuth Lotion: 






R. Bismuth, subnitrat., 
Zinci oxidi, 
Glycerini, 
Hydrarg. bichlor., 
Aquae rosae, 


gr. vijss ; 

g r - 1; 


2 

1 

32 



For rosacea and hyperaemic conditions. 



M. 



M. 



016 



M. 



716 



APPENDIX. 



3. Calamine Liniment : 

R. Pulv. calamin., gr. xl ; 2 

Zinci oxidi, £ss ; 2 

Linimenti calcis, ^j ; 32 

For erythema, eczema, and hypersemic conditions. 



m 



M. 



4. Calamine Lotion: 

R 



Pulv. calamin., 


gr. xx ; 


1 


Zinci oxidi, 


.^ss ; 


2 


Glycerini, 


§ss; 


15 


Aq. calcis, 


3yj ; 


24 


Aq. rosse, 


ad ^iv ; 


ad 128 



For erythema and eczema. (Bulkley. 



M 



5. Carbolic Acid Lotion : 

R. Acid, carbol., 
Alcoholis, \ 
Aquae destil., J 

For erysipelas. (White.) 



3J; 

aa Oss ; 



4 
aa 210 



M. 



6. Carron Oil: 

R. Aq. calcis, 
01. olivse vel 
01. lini, 
For burns. 



Equal parts. 



M. 



7. Coder's Paint: 

R. Iodini, 

01. picis liquids?, 



3j-ij I 4-8 

3J; 32 



M. 



8. Fox's C. C. C. Mixture : 

R. Chrysarobin., \ 
01. cadini, J 
Acid, carbolici, 
Acid, oleici, 
For psoriasis. 



aa 2 parts. 

1 part. 
50 parts. 



M. 



9. Hardaway's Lotion for Lichen Planus: 

R. Sapo. olivse prsep., %iv ; 

01. rusci, i __-._, 
Glycerini, J ®S >•' 

01. rosmarini, 3J SS ! 

Alcoholis, ad Jviij ; 



128 

aa 32 

6 
ad 256 



M. 



APPENDIX. 



717 



10. Kaposi's Tar Lotion: 

R. 01. rusci, 

JEtheris sulphuris, 

Alcohol is, 
Filtra et adde 

01. lavandulae, 
Used in psoriasis. 



50 parts, 
aa 75 " 



M. 



11. Kummerfeld' s Lotion . 

R. Spts. camphorse, 
Spts. lavandulae. 
Sulph. praecip., 
Aq. cologniensis,. 
Aquae destil., 
For cosraetique. 



3ss 



gr. xv ; 


I 


3j; 


4 


3ij; 


64 



M. 



12. Liquor Picis Alkalinus : 

R. Picis liquidae, 3ij ; 641 

Potass, causticae, 3 j ; 32 

Aquae destil., ^v; 20' M. 

Dissolve the potassa in the water and add slowly the tar in a 
mortar with friction. 
For chronic eczema, or, diluted ten to twenty times, for acute eczema. 

13. Lotio Alba: 

R. Potassae sulphurat., \ 
Zinci sulphat., J 

Aquae rosa?, ad 3iv 

For acne and rosacea. 



aa 3j; 



aa 4 
ad 128 



M. 



14. Lotio Ac. Boracis: 

R. Ac. boracis, ^iv vel q. s. ; 16 

JEtheris sulph. methyl., 3v. ; 160 

Spts. vini rect., ad ^xx ; ad 640 M. 

For ringworm, after washing with hot water and soap, and drying. 
(A. Smith.) 



Mo 



15. Lotio Plumb i et Opii: 








R. Liq. plumbi subacetat. 
Tinct. opii, 
Aquae destil., 


dil 


'' } aa 3J; 
ad Oj ; 


aa 32 
ad 500 


For acute inflammatory conditions 






16. R. Naphtoli, 

Spts. sapo. viridis, 
Alcoholis, 




gr. xv ; 
ovj ; 

oJ s s ; 


1 
24 
45 


Bals. pern v., 
Sulph. loti, 




gtt. xxx ; 

3iJ ss ; 


2 
10 


For sycosis. (Kaposi.) 









M, 



718 



APPENDIX. 



17. R. Amyli glycerolis, \ 

01. cadini, / 

Sapo viridis, 
For psoriasis. External use. 

18. Piffard's Substitute for Tar 

R. Ac. salicyl., 
Ol. lavandulse, 
Ol. citronella?, 
01. pini sylvestris, 
01. ricini, 

For eczema capitis. 



aa, 100 parts. 
5 " 



gr. x-xxx 

,^ss ; 



19. R. Sodii hypophosphitis, ^j; 

Glycerini, ^ss ; 

Aquae destil., ^viij ; 

For dermatitis venenata. (Morrow.) 



0.66-2 

10 

2 

60 

45 



32 

16 
256 



M. 



M. 



M. 



20. Sulphur Lotion: 

R. Sulphuris loti, 1 
Alcoholis, 
jEtheris, 
Glycerini, 
Potass, carb., 
Aq. rosae, 

Used in acne. 



aa, ^ij ; aa 8 
3 vij ; ad 250 



M. 



21. Thymol Lotion : 

R. Thymol., \ 

Liq. potassse, / 
Glycerini, 
Aq. sambuci, 



aa 3j ; aa 4 

|e»; 16 

^viij ; ad 256 



M. 



For seborrhoea sicca capitis. Also for pruritus cutaneus, with double 
the amount of thvmol. 



22. Tinctura Saponis Viridis 

R. Sapo. viridis, "> 
Alcoholis, J 



Equal parts. 



M. 



23. Tinct. Saponis Co. of Hebra: 

R. Ol. cadini, 

Sapo. 

Alcoholis, 
Filtra et adde 

Spts. lavandulse, 
Stimulant in chronic eczema. 



cadini, ~\ 

>. viridis, > 
>holis, J 



aa 3j; 



aa 32 



M. 



APPENDIX. 



719 



24. Vleminckx's Solution : 

R. Calais vivse, 3'v; 161 

Sulphur, sublimat., t ^j ; 32 

Aq. destil., '% x ; 3201 M. 

Boil together with constant stirring until the mixture measures 
six fluid ounces, then filter. 
Useful in scabies, psoriasis, and acne. 



25. R. Zinci oxidi, 
Ac. carbol., 
Aquae calcis, 

For dermatitis venenata. 



1. Bassorin Paste: 

R. Bassorin, 
Dextrin, 
Glycerin, 
Water, 

2. Gelatin Paste (Unna 

R. Zinci oxidi, 

Gelatini, 

Glycerini, 

Aqua? destil., 
Heat in water bath before using. 
As a protective dressing and excipient 



J5iv ; 


16 


3J : 
ad Oj; 


4 
ad 500 


(White.) 




c. Ointments. 






48 parts. 
25 " 




10 " 


ad 


100 " 




30 parts. 

30 " 




39 " 




10 " 



M. 



M. 



M. 



3. Bismuth Ointment: 

R. Bismuth! subnit., 
Kaolini, 
Vaselini, 
For chloasma. (Unna.) 



aa £jss ; 
ad 3 



aa 6 
ad 48 



M. 



4. R. Ac. borici, gr. x ; 

Ac. salicylici, gr. xv 

Ungt. aqua? rosse, 5)j ; 

For chromidrosis. (Van Harlingen.) 



M. 



5. Chrysarobin Ointment: 






R. Chrysarobin., 
Ac. salicylici, 
Plasment. ve4 ") 
Adipis, j 


gr. 1; 
gr. x ; 

ad £; 


3 
ad 32 


Used in psoriasis and ringworm, 







M. 



720 



APPENDIX. 



6. R. Chrysarobin., \ 
Ichthyol., / 

Ac. sal icy 1., 
Ungt. simpl., 
Used in leprosy. ( Unna. ) 



aa gr. lxxv ; aa 5 



gr. xxx ; 
ad giij ; 



2 
ad 126 



M. 



7. Diachylon Ointment (Hebra) : 

R. 01. olivse, E xy > 

Plumbi oxidi, giij gvj ; 

Boil together to a good consistence and add 



01. lavandulae, 



3y; 



450 
120 

81 



8. R. Hydrarg. ammon., \ 
Bismuthi subnit., J 
Ungt. aq. rosse, 

Used in lentigo. (Hardaway.) 



aa jjj; 
adgj; 



aa 4 
ad 32 



M. 



9. R. Hydrarg. ammon., 

Hydrarg. chlor. mitis, 
Vaselini, 



gr- 



5-10 



gr. xl-lxxx ; 10-20 



adgj- 



ad 100 



M. 



Used in seborrhoea sicca capitis and pityriasis capitis. (Bronson. 



M. 



10. 

Use 


R. Hydrarg. bichlor., 
Ac. carbol., 
Ungt. zinci oxidi, 

rl in lichen ruber. (Unna.) 


gr. j-v; 
gr. xx ; 
ad $j; 


0.6-0.3] 
1.3 
ad 32 


11. 


R. Ac. salicylici, 

Ungt. hydrarg. ox. rub. 
Ungt. aquse rosse, 


gr. x ; 

> 35; 

3 v j ; 


4 
24 



For blepharitis. (Webster.) 



M. 



12. R. Hydrarg. protiodid. 

Hydrarg. ammon., 
Ungt. simplicis, 
Used in acne. (Duhring.) 

13. R. Ungt. lanse, 

Ac. acetici, 
Adepis benzoat., 
Sulph. prsecip., 
Used in acne. (Unna.) 



gr. v-xv; 0.33-1 
gr. x-xxx; 0.66-2 

.lj; 



a»y g r - xlv ; 
3U ss ; 

gr. xlv ; 



32 



M. 



31. 



14. R . Hydrarg. sulph. rubri, gr. xv ; 1 

Sulph. sublimat., ,^vj ; 24 

Adipis, ad giij ; ad 100 

Ol. bergamot., q. s. ; q. s. 

Used in sycosis. (Behrend.) 



M. 



APPENDIX. 



721 



15. R. Ungt. diaeliyli (Hebra), j 
Ungt. zinci oxidi, J 

Ungt. hydrarg. amnion., 
Bismuthi subnitrat., 

For sycosis. (Kobinson.) 



16. 



Lassar's Paste : 
R. Zinci. oxidi, 
Amyli, 
Vaselini, 



aa 5jss 
oJ ss ! 



aa 31J ; 

3iv 



aa 48 

12 
6 



ad 32 



M 



M. 



As a protective application and as an excipient for other drug 

40 parts, 
aa 20 " 



i\ 



15 
10 

50 
100 



M. 



aa 25 



17. R. Zinci oxidi, 
Creta prseparat., 
Liquor plumbi, 
01. lini, 

Mix the first two together, and the last two together, and add one 
part to the other. 
Use as a protective in eczema. (Unna.) 

18. Naphtol Ointment: 

R. /^-naphtol., ^iij gr. xl ; 

Creta prseparat., olJ sy 5 

Sapo. viridis, 3jss ; 

Adipis, ad Jiij ; ad 

Used in scabies. (Kaposi.) 

19. Naphtol Ointment : 
R. ^-naphtol., 10 parts. 

Sulph. prsecip., 50 " 

Vaselini, 1 

Sapo. viridis, / 
Used in acne. (Lassar.) 

20. R. Ac. salicylici, 

Sulphur, prsecip., 
Lanolini, 
Vaselini, 
For chromophytosis. (Brocq.) 

21. R. Sulphur., 

Potass, carb., 
Adip. benzoat., 

01. chamomilis, gss ; 2 M. 

Used in scabies. (Wilson.) 

22. Helmerich? s Ointment: 
R. Sulphur., 

Potass, carb., 

Adipis, 3viij : 256 M. 

Used in scabies. A- 



M. 



e 


5-3 


parts. 


10- 


-15 
70 


« 




18 


a 


3.i ; 




32 


#j ; 




8 


.?v; 




160 


gss; 




2 


ffj; 




32 


3; 




16 


3 VJ1 J 




256 



22 APPENDIX. 
23. Wilkinson's Ointment (Hebra) : 






R. Sulpliuris, | 
01. cadini, J 






aa 3ss ; 


aa 16 




Sapo. viridis, ) 
Adipis, J 


aa gj ; 


aa 32 




Creta praeparat, 


Sijss ; 


10 


M. 


Used in scabies. 






24. R. 01. fagi, \ 
Flor. sulph., J 


aa 3ijss; 


aa 10 




Pulv. cretae alb., 


3J; 


4 




Adipis, \ 
Sapo. viridis, J 


aa 3v; 


aa 20 


M. 


For sycosis. (H. Hebra.) 






25. R. Ol. cadini, 1 
Zinci oxidi, J 




, 


aa 5ss-j ; 


aa 2-4 


Ungt. aquae rosae, 


S; 


32 M. 


For chronic eczema. 






26. R. Zinci oxidi, 1 
Zinci carbonat., J 






aa 3j ; 


aa 4 




Ungt. aq. rosae, 


ad S ; 


ad 32 


M. 


For sycosis after shaving. (T. 


Fox.) 




27. R. Terra? siliceae, 


gr. xx ; 


1 


33 


Zinci oxidi, 


#j; 


8 




Adipis benzoat., 


ad Si 


ad 32 








(Unna.) 


28. R. Terrae siliceae 


^ss; 


2 




Sulphur, prsecipitat., 


ojj; 


8 




Zinci oxidi, 


,^iss ; 


6 




Adipis benzoat, 


ad gj; 


ad 32 








(Unna.) 


d. Miscellaneous. 




1. Anti-pruritic Powder : 






R. Camphori, 


3&s; 


2 




Zinci oxidi, 


Sq; 


8 




Amyli, 


3iv; 


16 


M. 






(Bulkley.) 


2. Corn Remedy : 






R. Ac. salicylici, 


gr. xv ; 


1 




Ex. cannabis indicae, 


gr. viij ; 




5 


Alcoholis, 


Ti\xv; 


1 




iEtheris, 


tilxl; 


2 


66 


Collodion flex., 


TT^lxxv; 


5 


M. 


Apply with brush three ti 


mes a day for a week. Soak feet and 


pick out com. (Vig 


er.) 







APPENDIX. 



723 



3. Ep Hating Stick : 

R. Cerae flavae, 3'uj ; 12 

Laccae in tabulis, giv ; 16 

Picis burgundicae, £x ; 40 

Gummi damar., ^jss ; 48j M. 
Make in stick one-half to one inch in diameter and two inches 
long. (Bulkley.) 



. Glycerin Jelly : 






R. Gelatini, 


gr. xxv ; 


1 


Glycerini, 


gr. ccxxv ; 


15 


Aquae destil., 


3iv; 


16 



(56 



M. 



Glycerole of Subacetate of Lead : 
R. Plurabi acetat., gr. cxx; 8 

Plumbi oxidi, gr. lxxxiv ; 6 

Glycerini, Jj ; 32 M. 

Digest the lead in the glycerin heated to 300° F. in an oil bath 
for half an hour, constantly stirring. Filter in a chamber 
heated to 300° F. 
Dilute from three to seven times with water and glycerin, and 
use as astringent and sedative in chronic eczema. (Squire.) 



6. Unna's Superoxide of Soda Soap . 
R . Superoxide of soda, 
Liquid paraffin, 
Fully dried-out soap, 



5 to 20 per cent, in 
30 parts, 
70 '< 



INDEX. 



A BSCESS, 67 

ft- Acanthosis nigricans, 68 
Acantholysis, 68 

bullosa, 266 
Acarus scabiei, 569 
Achorion Schoenleinii, 310 
Achroma, 696 
Acid oxynaphthoic, 54 
Acne, diagnosis, 75 
etiology, 72 
pathology, 74 
prognosis, 85 
symptoms, 69 
treatment, 77 

bromic, 191 

agminata, 87 

albida, 443 

artificialis, 86 

atrophica, 86 

cachecticorum, 86 

erythematosa, 552 

follicularis, 155 

frontalis, 87 

iodic, 193 

keloid, 195 

keratosa, 87 

lupoid, 87 

mentagra, 596 

necrotica, 87 

necroticans et exulcerans 
nasi, 89 

pilaris, 87 

punctata, 69, 155 

rodens, 87 

rosacea, 557 

scrofulosorum, 86 

sebacea, 586 

sycosis, 596 

tar, 86 

telangiectodes, 87 

urticata, 89 

varioliformis, 87, 320, 445 
Acne arthritique, 87 

fluente, 586 

keloidique, 195 

miliaire scrofuleuse, 87 

punctuee, 155 

sebacee cornee, 381 

ulcereuse, 87 



Acnits, 87 
Acrochordon, 319 
Acrodermatitis chronica atrophi- 
cans, 90 

perstans, 90 
Acrodynia, 90 
Acromegalia, 261 
Acromegaly, 91 
Actinomycosis, 91 
Adeno-carcinoma, 92 
Adenoma sebaceum, 92 

sudoriferum, 93 
Adenotrichie, 597 
Ainhum, 93 
Airol, 50 
Albinism, 94 
Aleppo boil, 94 

bouton, 94 

evil, 94 
Algidite progressive, 576 
Alopecia adnata, 95 

areata, diagnosis, 110 
etiology, 108 
pathology, 110 
prognosis, 114 
symptoms, 105 
treatment, 111 

atrophica, 324 

circumscripta, 105 

follicularis, 105 

furfuracea, 100 

pityrodes, 100 

prematura idiopathica, 96 
symptomatica, 100 

senilis, 95 

syphilitica, 103 
Alopecies cicatricielles innomi- 

nees, 322 
Alphos, 523 
Althal, 50 
Alumnol, 51 
Anaesthesia, 114 
Analgesia, 114 
Angiomyoma, 454 
Angiokeratoma, 114 
Angioma, 458 

pigmentosum et atrophicum 
123 

serpiginosum, 116 

725 



726 



INDEX. 



Anhidrosis, 117 
Anidrosis, 117 
Anonychia, 117 
Anthrarobin, 51 
Anthrasol, 51 
Anthrax, 137, 548 
Area celsi, 105 

occidentalis diffluens, 105 

serpens, 105 

tyria, 105 
Argyria, 117 
Arrectores pilorum, 27 
Asiatic pill, 713 
Asteatosis, 118 
Atheroma, 161 
Atoxyl, 51 
Atrophia cutis, 123 

pilorum propria, 118 

unguium, 122 
Atrophoderma, 123 

albidum, 126 

idiopathica diffusa, 126 
Atrophoderma pigmentosum, 123 

senilis, 127 

striatum et maculatum, 128 
Aussatz, der, 393 

BACILLUS acnes, 75 
lepras, 399 
prodigiosus, 148 
Bad disorder, 607 
Baelzer's disease, 129 
Baldness, 95 

circumscribed, 105 

congenital, 95 

premature, 96 

senile, 95 
Barbadoes leg, 259 
Barber's itch, 597, 661 
Bartfinne, 597 

parasitische, 661 
Bartflechte, 597 
Bassorin, 491, 719 
Bath's, 711 
Bedbug bites, 475 
Beigel's disease, 129 
Birthmark, 458 
Blackheads, 155 
Blasenausschlag, 485 
Blastomycetic dermatitis, 165 
Bloodvessels, 21 
Blutfleckenkrankheit, 542 
Blutschwar, 329 
Boil, 329 

Botryomycosis hominis, 130 
Bougard's paste, 275, 714 
Bouton, 69 
Brandrose, 131 



Brandschwar, 137 
Bromidrosis, 131 
Bromotan, 51 
Bronson's ointment, 204 
Bucnemia tropica, 259 
Bulla, 33 
Bulpiss, 132 
Bunion, 133 
Burning, 45 

/HACOTROPHIA folliculorum 

\J 386 

Calamin lotion, 716 

Calculi, cutaneous, 443 

Callositas, 133 

Callosity, 133 

Callus, 133 

Callotte, 313 

Caivities, 95 

Cancer, Chimney-sweep's, 269 

en-cuirasse, 140 

epithelial, 267 

skin, 267 

tubereux, 378 
Cancroid, 267 
Canities, 134 
Canquoin's paste, 715 
Caraate, 497 
Carbon dioxide, 59 
Carbuncle, 137 
Carcinoma, 140 

lenticulare, 140 

melanodes, 141 

tuberosum, 141 
Carron oil, 716 
Causalgia, 164 
Chalazion, 443 
Chalazodermia, 211 
Chaleur du foie, 143 
Chancre, 607 
Chap, 141 
Charbon, 548 
Cheilitis exfoliativa, 142 

glandularis aposthematosa, 
142 
Cheiro-pompholyx, 508 
Cheloide, 378 
Chicken-pox, 690 
Chigoe, 474 
Chilblain, 170 

necrotising, 320 
Chloasma, diagnosis, 145 
etiology, 144 
prognosis, 146 
symptoms, 143 
treatment, 145 

uterinum, 144 
Chorionitis, 577 



INDEX. 



727 



Chromidrosis, 146 
Chromophytosis, 148 
Cicatrix, 36 
Cimex lectularius, 475 
Claret stain, 458 
Classification, 61 
Clastothrix, 119 
Clavus, 153 

syphiliticus, 154 
Clou, 329 
Cnidosis, 687 
Cochin-China leg, 259 
Cold sore, 339 
Colloid degeneration, 154 

milium, 154 
Columnae adiposae, 21 
Comedo, 155 
Condyloma acuminata, 694 

lata, 616 
Congelation, 58 
Connective tissue, subcutaneous 

21 
Cor, 153 
Corium, 20 
Corn, 153 

Corne de la peau, 160 
Cornu cutaneum , 160 

humanum, 160 
Corpuscles of Krause, 22 

of Meissner, 22 

Pacinian, 22 

tactile, 22 
Cosme's paste, 714 
Coster's paint, 716 
Couperose, 552 
Crab louse, 478 
Craw-craw, 161 
Crust, 34 

Crusta lactea, 243 
Cute, 497 
Cutis anserina, 161 

pendula, 211 
Cyanopathie cutanee, 146 
Cyst, dermoid, 161 

sebaceus, 161 
Cystecercus cellulosae cutis, 163 

DACTYLITIS, 637 
Dandruff, 587 
Dartre eryth6moide, 285 

humide, 216 

pustuleuse mentagre, 596 

rongeante, 429 

vive, 216 
Dasyma, 352 

Defluvium capillorum, 104 
Demodex folliculorum, 157 
Depilatory paste, 714 



Dermatalgia, 163 
Dermatitis ambustionis, 168 
blastomycotica, 165 
bullosa, 266 
calorica, 168 
coccidioides, 167 
congelationis, 169 
contusiforme, 296 
epidemica, 171 
erythematosa, 285 
exfoliativa, diagnosis, 175 
etiology, 174 
pathology, 175 
prognosis, 177 
symptoms, 173, 174 
treatment, 176 
exfoliativa neonatorum, 177 
factitia, 177 
fungoid, 450 
gangrenosa, 178 
gangrenosa, infantum, 180 
glandularis erythematosa, 41 9 
herpetiformis, diagnosis, 187 
etiology, 186 
pathology, 186 
prognosis, 188 
symptoms, 182 
treatment, 188 
malignant papillary, 468 
medicamentosa, 189 
papillaris capillitii, 195 
papillomatosa capillitii, 195 
psoriasiformis, 473 
psoriasiformis nodularis, 498 
repens, 197 

seborrheica, diagnosis, 202 
etiology, 201 
pathology, 201 
prognosis, 205 
symptoms, 199 
treatment, 203 
traumatica, 205 
uncinarial, 682 
variegata, 473 
vegetans, 210 
venenata, diagnosis, 208 
pathology, 207 
symptoms, 205 
treatment, 208 
verrucosa, 210 
x-ray, 198 
Dermatol, 51 
Dermatolysis, 211 
Dermatomycosis favosa, 305 
microsporina, 148 
tonsurans, 657 
Dermato-sclerosis, 577 
Dermatosis Kaposi, 123 



728 



INDEX. 



Desmoides, 319 
Dhobie itch, 212 
Diabetic eruptions, 212 
Diagnosis, general, 29 

color in, 44 

configuration in, 38 

history in, 45 

location in, 36 

microscope in, 46 
Diaskop, 47 
Diphtheria of skin, 212 
Distichiasis, 213 
Dracontiasis, 337 
Duhring's disease, 182 
Durillon, 133 
Dysidrosis, 508 

ECDERMOPTOSIS, 445 
Ecphyma globulus, 214 
Ecthyma, 214 

infantile gangreneux, 180 
terebrant de l'enfance, 180 
Eczema, diagnosis, 221 

etiology, 222 

pathology, 224 

prognosis, 240 

symptoms, 217 

treatment, 229 
ani, 241 
aurium, 242 
barb ae, 243 
capitis, 243 
crurum, 246 
exfoliativum, 172 
foliaceum, 172 
genitalium, 246 
hypertrophicum, 450 
infa,ntile, 255 
intertrigo, 247 
labiorum, 218 
madidans, 220 
mammarum, 248 
mammillarum, 248 
manuum, 249 
marginatum, 656 
narium, 252 
orbicular, 221 
palpebrarum, 252 
pedum, 253 
rubrum, 220 
seborrhoicum, 199 
tuberosum, 450 
unguium, 254 
universale, 254 
varicosum, 222 
verrucosum, 222 
Eigon, 52 
Eiterpusteln, 214 



Elastic skin, 211 
Elastic webbing, 49 
Elephantiasis, diagnosis, 262 
etiology, 261 
pathology, 262 
prognosis, 264 
symptoms, 260 
treatment, 263 
Arabum, 259 
Grecorum, 393 
Indica, 259 
Emol, 52 

Emphysema of skin, 264 
Empyroform, 52 
Endermol, 50 
Endothelioma, 264 
Endurcisement athrepsique, 576 
Ephelides, 391 
Ephidrosis, 348 
cruenta, 338 
tincta, 146 
Epidermis, 17 
Epidermodophyton, 532 
Epidermolysis bullosa, 266 
Epilating stick, 723 
Epithelialkrebs, 267 
Epithelioma, diagnosis, 272 
etiology, 270 
pathology, 271 
prognosis, 277 
symptoms, 267 
treatment, 273 
adenoides cysticum, 278 
contagiosum, 445 
multiple benign cystic, 277 
Epitheliomatose pigmentaire, 

123 
Equinia, 278 
Erbgrind, 305 
Eruption, creeping, 361 
feigned, 177 
recurrent summer, 347 
ringed, 38 
Erysipelas, diagnosis, 2S2 
etiology, 281 
prognosis, 284 
symptoms, 279 
treatment, 283 
chronic, 285 
suffusum, 285 
Erysipeloid, 285 
Erythema, 285 
annulare, 294 
bullosum, 294 
caloricum, 287 
circinatum, 294 
elevatum diutinum, 300 
epidemicum, 90 



INDEX. 



729 



Erythema, exudativum, 292 

fugax, 289 

gyyatum, 294 

hyperaemicum, 28G 

induratum scrofulosorum, 301 

intertrigo, 287 

iris, 295 

laeve, 289 

marginatum, 294 

migrans, 285 

multiforme, diagnosis, 298 
etiology, 297 
pathology, 298 
prognosis, 300 
symptoms, 293 
treatment, 299 

neonatorum, 290 

nodosum, 296 

paratrimma, 289 

pernio, 170, 287 

perstans, 294 

roseola, 289 

scarlatiniforme, 280 

simplex, 287 

tuberculatum, 294 

traumaticum, 287 

urticans 289 
Erytheme centrifuge, 419 

noueux, 296 

papuleux desquamatif, 499 
Erythrasma, 302 
Erythrodermia, congenital ich- 

thyosi forme, 303 
Erythrodermic enfoliante, 172 

pityriasique en plaques 473 
Erythromelalgia, 304 
Esthiomene, 304, 429 
Eugallol, 52 
Europhen, 52 

Examination of patient, 46 
Exanthem, psoriasiform and 

lichenoid, 473, 498 
Excoriation, 35 

FARCY, 278 
Favus, diagnosis, 311 

etiology, 309 

pathology, 310 

prognosis, 316 

symptoms, 306 

treatment, 312 
Feigned eruptions, 177 
Feu sacre, 279 
Feuergurtel, 706 
Feuermal, 458 
Fever-blister, 339 
Fibroid, recurrent, 563 
Fibroma, 317 



Fibroma fungoi'des, 450 

lipomatodes, 700 

molluscum, 317 

pendulum, 317 
Fibromyoma, 454 
Fikosis, 597 
Filmogen, 52 
Finnen, 69 
Finsen light, 56 
Fischschuppenausschlag, 363 
Fish -skin disease, 363 
Fissure, 35 
Flea bites, 320, 474 
Flechte, fressende, 429 

kleien, 148 

nassende, 216 

scheerende, 654, 657 
Fleckenmal, 455 
Fleshworms, 155 
Fluxus sebaceus, 586 
Folliclis, 320 
Folliculitis, 321 

desseminees des parties glab- 
res, 320 
Folliculitis barbae, 596 

decalvans, 322 

depilating of limbs, 327 

pilorum, 596 
Foot, tubercular disease of, 328 
Fordyce's disease of lips, 327 
Fragilitas crinium, 118 
Franibcesia, 195, 705 
Freckles, 391 
Friesselauschlag, 441 
Frost bite, 169 
Fuchsine, 53 

Fungous foot of India, 328 
Furuncle, 329 
Furunculi atonici, 214 
Furunculus, diagnosis, 331 
etiology, 330 
pathology, 331 
prognosis, 334 
symptoms, 329 
treatment, 331 

GALE, 567 
Gallacetophenone, 53 
Gangrene, multiple cachectic, 180 

symmetrical, 179 
Gefassmal, 458 
Gelanthum, 49 
Gelatine preparations, 48 

paste, 719 
Gerromorphism cutanee, 335 
Glandular disease of Barbadoes f 

259 
Glands, sebaceous, 26 



730 



INDEX. 



Glands, sweat, 26 

Glanders, 278 

Glossy skin, 127 

Gnat bites, 475 

Gneis, 586 

Goose-flesh, 161 

Granuloma, coccidioidal, 167 

fungoides, 450 

innominee, 320 

necrotica, 320 

pyogeticum, 336 

trichophyticum, 659 

tropicum, 705 
Granulosis rubra nasi, 336 
Grayuess, 134 
Grubs, 155 
Grutum, 443 

Guinea-worm disease, 337 
Gum, red, 549 
Gumma, scrofulous, 584 

syphilitic, 626 
Giirtelkrankheit, 706 
Gutta rosacea, 552 

rosea, 552 

H^EMATIDROSIS, 338 
Haemidrosis, 338 
Haemorrhoea petechialis, 542 
Hair, anatomy of, 24 

blanching of, 134 

discolorations of, 338 

ringed, 122, 135 

superfluous, 352 
Hand and foot disease, 493 
Harlequin foetus, 365 
Harvest bug, 474 
Hauthorn, 140 
Hautnervenschmerz, 163 
Hautrose, 279 
Hautrothe, 285 
Hautschmerz, 163 
Hautsclereme, 577 
Hautwurmer, 155 
Heat eruption, 216 
Helmerich's ointment, 721 
Hemiatrophia facialis progres- 
siva, 127 
Henoch's purpura, 545 
Hernia carnosa, 259 
Herpes circinatus, 182, 295, 654, 
657 

esthiomenes, 429 

facialis, 339 

febrilis, 339 

gestationis, 182, 344 

iris, 295 

labialis, 339 

phlyctaenodes, 182 



Herpes preputialis, 341 

progenitalis, 341 

pustulosus mentagra, 596 

squamosus, 657 

tonsurans, 657 

tonsurans barbae, 661 
maculosus, 499 

Zoster, 706 
Herpetide, 344 

exfoliative, 172 
Hide-bound disease, 577 
Hidrocystoma, 344 
High-frequency current, 58 
Hirsuties, 352 
Hitzblatterchen, 216 
Hives, 683 
Homines pilosi, 353 
Horn, cutaneous, 160 
Huhnerauge, 153 
Hutchinson's teeth, 636 
Hyalom der Haut, 154 
Hvdroa, 182, 295 

bulleux, 182, 185 

febrilis, 339 

herpetiforme, 185 

puerorum, 347 

vacciniforme, 347 

vesiculeux, 296 
Hydrosadenite disseminee sup- 
purative, 320 
Hydroxylamine, 53 
Hyperesthesia, 348 
Hyperalgesia, 348 
Hyperidrosis, 348 

oleosa, 590 
Hyperkeratosis atrophica, 511 

excentrica, 511 

follicularis, 386 

linguae, 130 
Hypertrichosis etiology, 355 

symptoms, 352 

treatment, 358 
Hyponomoderma, 361 

TCHTHALBIN, 53 

X Ichthyose anserine des scro- 

fuleux, 386 
Ichthyosis, diagnosis, 367 
etiology, 366 
pathology, 366 
prognosis, 368 
symptoms, 363 
treatment, 367 
congenita, 365 
follicularis, 381, 386 
hystrix, 472 
intra-uterina, 366 
linguae, 403 



INDEX. 



731 



Icthyosis palmaris et plantaris, 
385 

sebacea, 586 

vera, 363 
Idrosis, 348 
Ignus sacer, 706 
Impetigo, Bockhardts, 369 

contagiosa, diagnosis, 373 
etiology, 372 
pathology, 373 
prognosis, 376 
symptoms, 370 
treatment, 376 

herpetiformis, 376 

parasitica, 370 

simplex, 369 
Induratio telae cellulosae, 576 
Initial lesion, 607 
Intertrigo, 287 
Iodic acne, 193 
Iodolen, 53 
Ionthus, 69 

Iron electrode lamp, 56 
Isarol, 53 
Itch, 567 

barber's, 597, 661 

bricklayer's, 249 

Dhobie, 212 

grocer's, 249 

prairie, 513 

washerwoman's, 249 
Ixodes, 475 

TIGGER, 474 
O Juckblattern, 513 

KAHLHEIT, 95 
kreisfleckige, 105 
Kelis, 378 
Keloid, 378 

Addison's, 580 

Alibert's, 378 
Keratolysis exfoliativa, 381 
Keratoma, 133 

follicularis, 365 

palmare et plantare, 385 
Kerratosis diffusa, 365 

epidermica, 365 

follicularis, 381 

follicularis contagiosa, 384 

intra-uterina, 365 

palmaris et plantaris, 385 

pilaris, 386 

senilis, 387 
Kerion, 388 

Celsi, 388 
Knollenkrebs, 378 
Koilonychia, 390 



Koltum, 507 
Kratze, 567 
Kraurosis vulvae, 390 
Kummerfeld's lotion, 717 
Kupferfinne, 552 
Kupferrose, 552 
Kupfrige gesicht, 552 
Kwe-na, 391 

LARVA migrans, 361 
Lassar's paste, 721 
Leberflecken, 143 
Leichdorn, 153 
Lenicet, 53 
Lentigo, 391 

maligna, 123, 391 
Leontiasis, 393 
Lepothrix, 393 
Lepra, diagnosis, 400 
etiology, 399 
pathology, 399 
prognosis, 402 
symptoms, 394 
treatment, 400 
alphos, 523 
arabum, 393 
grecorum, 523 
Leprosy, 393 

Lombardian, 483 
Leptus autumnalis, 474 
Leucasmus, 696 
Leucoderma, 696 
Leucokeratosis buccalis, 403 
Leuconychia, 403 
Leucopathia, 696 
unguium, 403 
Leucoplakia, 403 
Lichen annularis, 405 
circinatus, 588 
hypertrophicus, 411 
menti, 596 
obtusus, 411 

corneous, 405 
pilaris, 386, 406 
planus, diagnosis, 412 
etiology, 411 
pathology, 411 
prognosis, 414 
symptoms, 407 
treatment, 412 
ruber acuminatus, 414 
moniliformis, 410 
planus, 407 
scrofulosorum, 417 
scrofulosus, 417 
simplex, 219 
spinulosus, 406 
tropicus, 441 



732 



INDEX. 



Lichen urticatus, 684 
variegatus, 473 
verrucosus, 411 
Lineae albicantes, 129 
Lines, symptomatic, 128 
Linsenflecke, 391 
Linsenmal, 455 
Liodermia essentialis c. melanosi 

et telangiectasia, 123 
Lipoma, 419 
Liquid air, 60 
Liquor anthracis, 54 

picis alkalinus, 717 
Liver spot, 143 
Lotio alba, 717 

plumbi et opii, 717 
Lousiness, 476 
Lues, 606 

Lupus erythemateux disseminee 
320 
erythematodes, 419 
erythematosus, diagnosis, 424 
etiology, 424 
pathology, 423 
prognosis, 427 
symptoms, 419 
treatment, 425 
exulcerans, 430 
hypertrophicus, 430 
lymphaticus, 439 
pernio, 428 
sclereux, 675 
sebaceus, 419 
superficialis, 419 
verrucosus, 675 
vulgaris, diagnosis, 433 
etiology, 431 
pathology, 432 
prognosis, 438 
symptoms, 429 
Lustseuche, 607 
Lymphadenie cutanee, 450 
Lymphangiectasis, 438, 439 
Lymphangietodes, 439 
Lymphangioma, 439 

tuberosum multiplex, 440 
Lymphatics, 21 

Lymphodermia perniciosa, 450 
L\mphorrhagica pachydermia, 
439 

MACULE coerulese, 479 
Maculae et striae atrophica^, 
128 
Macule, the, 29 

symptomatic, 128 
Madura-foot, 328 
Mai de la rosa, 483 



Mai roxo, 483 
Malingering, 177 
Maleus, 278 
Malum venereum, 606 
Mamillaris maligna, 468 
Marsden's paste, 714 
Mask, 143 
Measles, 448 

German, 560 
Melanoderma, 143 
Melanosarcoma, 562 
Melanosis lenticularis, progres- 
siva, 123 
Melasma, 143 
Melitagra, 243 
Melung, 441 
Mentagra, 596 
Mercury vapor lamp, 57 
Mergal, 54 
Microsporon anomceon, 501 

Audouini, 665 

furfur, 150 

minutissimum, 303 
Middlesex Hospital paste, 715 
Miliaria, 441 

crystallina, 441 
Miliary fever, 443 
Milium, 443 
Milk crust, 243, 255 
Mitesser, 155 
Mixed treatment, 712 
Mole, pigmentary, 455 
Molluscum cholesterique, 700 

contagiosum, 445 

epitheliale, 445 

fibrosum, 317 

pendulum, 317 

sebaceum, 445 

sessile, 445 

simplex, 317 

verrucosum, 445 
Monilethrix, 122 
Morbilli, 448 
Morbus elephas, 259 

Gallicus, 606 
• Hispanicus, 606 

Indicus, 607 

Italicus, 606 

maculosus Werlhoffii, 544 

Neapolitanus, 607 

pedicularis, 476 
Morococcus, 207 
Morphoea, 580 
Morpion, 478 

Morvan's disease, 449, 650' 
Morve, 278 
Mosquitoe-bites, 475 
Moth-patch, 143 



IXDEX. 



733 



Mother's mark, 455 

Mower's mite, 474 

Mucous patch, 616 

Myasis externa dermatosa, 450 

Mycetoma, 328 

Mycosis framboesiodes, 195 

Mycosis fungoides, diagnosis, 452 

etiology, 451 

pathology, 451 

prognosis, 453 

symptoms, 450 

treatment, 453 
Mycosis microsporina, 148 
Myoma, 453 
Myronin, 50 
Myxcedenia, 454 

VpEIVUS ARANEUS, 652 
1M flammeus, 459 

lipomatodes, 455 

nerve, 472 

pigmentosuSj 455 

pilosus, 455 

sanguineus, 458 

simplex, 459 

spilus, 455 

tuberosus, 459 

unius lateris, 472 

vascularis, 458 

vasculosus, 458 

venous, 459 
Naftalan, 54 
Nails, anatomy of, 25 

atrophy of, 122 

ingrowing, 466, 475 
Nectator Americanus, 6S2 
Neoplasm, inflammatory fung- 
oid, 45 ) 
Neuralgia of skin, 163 
Neurofibroma, 317 
Neuroma cutis, 463 
Nerves, 22 
Nesselausschlag, 6S3 
Nesselsuch, 6S3 
Nettlerash, 683 

Nodosites des arthritiques, 463 
Nodules, ephemeral cutaneous, 
463 

rheumatismal, 463 

subcutaneous rheumatic, 463 
Nodulus laqueatus, 464 
Noli me tangere, 267, 429 
Nosophen, 54 



DEMA, acute idiopathic, 464 

Angio neurotic, 464 
cutis, acute circumscribed, 

464 



(E 



(Edema, neonatorum, 465 
Oleum choenoceti, 50 

physeteris, 50 
Onychauxis, 465 
Onychia, 466 
Onychitis, 466 
Onychogryphosis, 465 
Onychomycosis, 467 
Ophiosis, 105 
Opsonins, 60 
Oriental sore, 94 
Osmidrosis, 131 
Osteosis cutis, 468 

PACHYDERMATOCELE, 211 
Pachydermia, 259 
Paget's disease, 468 
Pain, 46 

Panaris nerveux, 471 
Panne hepatique, 143 
Panniculus adiposus, 21 
Papillargeschwiilste, Beer- 

schwamahnliche, 450 
Papilloma, 471 

area elevatuin, 472 
lineare, 472 
neuroticum, 472 
Papule, 31 
Parakeratosis scutularis, 473 

variegata, 473 
Parangi, 705 
Parasitic diseases, 474 
Paronychia, 475 
Paste-pencils, 47 
Pedicularia, 476 
Pediculosis, diagnosis, 480 
etiology, 479 
symptoms, 476 
treatment, 482 
Pelade, 105 

Peliosis rheumatica, 545 
Pellagra, 483 

Pemphigus, diagnosis, 493 
etiology, 489 
pathology, 490 
prognosis, 492 
symptoms, 486 
treatment, 491 
acutus contagiosus, 370, 372 
a petites bulle, 182 
circinatus, 182 
gangrenosus, 180 
pruriginosus, 182 
vegetans, 487 
Perifolliculitis suppurees, 494 
Perisarcoma, 549 
Perleche, 495 
Pernio, 170 



734 



INDEX. 



Phagmesis, 496 
Phlegmasia Malabarica, 259 
Pbylyzaciagria, 214 
Phototherapy, 56 
Phthiriasis, 476 
Phvto-alopecia, 105 
Pian, 705 

ruboide, 195 
Piebald-skin, 696 
Piedra, 496 
Pigmentflecken, 143 
Pigmentmal, 455 
Pimple, 69 
Pinta, 497 
Pityriasis, 586 

alba atrophicans, 498 

capitis, 199, 506 

lichenoides chronica, 498 

maculata et circinata, 499 

nigricans, 146 

parasitaire, 148 

pilaris, 386 

rosea, diagnosis, 502 
etiology, 501 
pathology, 501 
svmptoms, 499 
treatment, 502 

rubra, 172 

rubra pilaris, etiology, 505 
diagnosis, 505 
pathology, 505 
symptoms, 503 
treatment, 506 

simplex, 506 

tabescentium, 507 

versicolor, 148 
Plasment, 49 
Plaster-muslins, 47 
Plica neuropathica, 507 

polonica, 507 
Podelcoma, 328 
Poils accidentels, 352 
Poison ivy eruption, 205 
Poliosis, 134 
Poliothrix, 134 
Polyidrosis, 348 
Polytrichia, 352 
Pompholyx, 485, 508 
Porcellanfriessel, 683 
Porokeratosis, 511 
Porrigo, 24 i 

contagiosa, 370 

decalvans, 105 

favosa, 305 

furfurans, 657 

lavalis, 305 

lupenosa, 305 

scutulata, 305 



Porrigo, true, 305 

Porrigophyta, 305 

Port wine mark, 458 

Pox, 607 

Prairie itch, 513 

Prickly heat, 441 

Proud flesh, 130, 336 

Prurigo, diagnosis, 515 
etiology, 515 
pathology, 515 
prognosis, 517 
symptoms, 513 
treatment, 516 

Pruritus, 45 

cutaneous, diagnosis, 520 
etiology, 518 
prognosis, 523 
symptoms, 517 
treatment, 520 

Pseudo-erysipelas, 523 

Pseudo-leucaemia cutis, 523 
lupus, 165 
pelade, 3^4 
xanthomelastique, 702 

Psora, 523 

Psoriasis, diagnosis, 532 
etiology, 530 
pathology, 531 
prognosis, 542 
symptoms, 524 
treatment, 534 
buccalis, 403 

Psorospermosis, 381 

Pterygium, 542 

Pulex, irritans, 474 
penetrans, 474 

Purpura, diagnosis, 547 
etiology, 545 
pathology, 546 
prognosis, 548 
symptoms, 542 
treatment, 547 

Pustula maligna, 548 

Pustule, 33 

Pyraloxin, 54 

QUINQUAUD'S disease, 324 
Quirica, 497 

RADIOTHERAPY, 57 
Radium, 58 
Ray fungus, 91 
Raynaud's disease, 179 
Recklinghausen's disease, 317 
Red gum, 442 
Resorbin, 50 
Rete malpighii, 19 
Rheumatism_of skin, 163 



INDEX. 



735 



Rhinophyma, 549 
Rhinoscleroma, 549 
Rhus poisoning, 206 
Ringskurv, 657 
Ringworm, 654, 657, 661 

crusted, 305 

honeycomb, 305 

Polish, 507 
Risipola, 279 

lombarda, 483 
Ritter's disease, 177 
Rodent ulcer, 270 
Roentgen rays, 57 
Rosacea, diagnosis, 555 
etiology, 554 
pathology, 555 
prognosis, 560 
symptoms, 552 
treatment, 556 
Rose, la, 279 

rash, 285 
Roseola, 289 

pityriaca, 499 
Rotheln, 560 
Rothlauf, 279 
Rotz, 278 
Rubella, 560 
Rubeola, 448 
Run-around, 475 
Rupia, 625 

escharotica, 180 

ST. ANTHONY'S FIRE, 279 
Sajodin, 54 
Salt rheum, 216 
Salve-muslin, 47 
Salve-pencils, 47 
Salzfluss, 216 
Sapolan, 54 

Sarcocele of Egyptians, 259 
Sarcoid, 561 
Sarcoma, diagnosis, 566 

etiology, 564 

pathology, 565 

prognosis, 566 

symptoms, 561 

treatment, 566 
Sarcoma cutis, multiple, 450 
Sarcomatosis generalis, 450 
Satyriasis, 393 
Sauriasis, 363 
Sauroderma, 381 
SaviU's disease, 171 
Scabies, diagnosis, 572 

etiology, 568 

pathology 569 

prognosis, 575 



Scabies, symptoms, 567 

treatment, 572 
Scald, 216 
Scale, 34 
Scall, 216 

head, 305 
Scar, hypertrophied, 379 

keloidal, 379 
Scarlatina, 575 
Scarlet fever, 575 
Schmeerfluss, 586 
Schuppenfiechte, 523 
Scissura pilorum, 118 
Sclerem der Neugeboren, 576 
Sclerema adultorum, 577 

neonatorum, 576 
Scleriasis, 577 
Sclerodactylie, 579 
Scleroderma, diagnosis, 581 
etiology, 581 
pathology, 581 
prognosis, 582 
symptoms, 577 
treatment, 582 

neonatorum, 576 
Scleroma adultorum, 577 
Sclerostenosis, 577 
Scrofulide boutonneuse, 513 

erythemateuse, 419 

tuberculeuse, 429 
Scrofuloderma, 583 

ulcerative, 450 

verrucosum, 675 
Scurvy, land, 544 
Seborrhagia, 586 
Seborrhoea, diagnosis, 590 
etiology, 589 
prognosis, 594 
symptoms, 586 
treatment, 592 

congestiva, 419 

corporis, 200 

nigricans, 146 
Shingles, 706 
Siderosis, 594 
Skin, anatomy of, 17 

bloodvessels of, 21 

cancer, 140, 267 

glossy, 127 

lesions of, 29 

lymphatics of, 21 

muscles of, 27 

nerves of, 22 

neuralgia of, 163 

physiology of, 28 

rheumatism of, 163 

splints, 48 



736 



INDEX. 



Smallpox, 691 
Soaps, 49 
Soap-pomade, 49 

superoxide of soda, 723 
Sommersprossen, 391 
Spargosis, 259 
Spedalskhed, 393 
Sphaceloderma, 178 
Spider cancer, 652 
Spilosis poliosis, 134 
Spiradenoma, 93 . 
Spoon nails, 390 

Sporotrichosis hypodermica, 594 
Spotted sickness, 497 
Startin's mixture, 713 
Stearrhcea, 586 

nigricans, 146 
Steatoma, 161 
Steatorrhea, 586 
Steresol, 55 

Stigmata, bleeding, 338 
Stone-pock, 69 
Stratum corneum, 18 

granulosum, 19 

mucosum, 19 
Streaks, idiopathic, 128 
Streptococcus of Fehleisen, 282 
Strophulus, 442 

albidus, 443 

prurigineux, 513 
Sudamina, 441 __ 
Sudatoria, 348 " 
Sudor urinosis, 682 
Sulphur cream, 203 
Summer eruption, 347 
Sunburn, 168 
Sweat, blue, 146 

glands, 26 

green, 148 

yellow, 147 

red, 147 
Sweating, excessive, 348 
Swelling, giant, 464 

periodic, 464 
Sycosis, diagnosis, 600 
etiology, 599 
pathology, 600 
prognosis, 606 
symptoms, 597 
treatment, 602 

capillitii, 195 

frambcesia, 195 

non-parasitica, 596 

parasitica, 661 
Syphilis, diagnosis, erythema- 
tous, 612; general, 631; 
gummatous, 628; papular, 
617 ; pustular, 619 ; pustu- 



lo-crustaceous, 626; squa- 
mous, 624 ; tubercular, 
622 ; ulcerative, 629. 

etiology, 632 

pathology, 632 

prognosis, 649 

symptoms, 607 

treatment, 637 

hereditary, 633 

initial lesion, 607 

secondary, 611 

tertiary, 620 
Syringo-cystadenome, 278 
Syringo-myelia, 650 

TACHE DE FEU, 458 
hepatique, 143 

ombree, 479 

vasculaire, 458 
Tanne, 155 

Tar, compound tincture of, 55 
Tattoo, 650 
Teigne du pauvre, 305 

faveuse, 305 

pelade, 10t> 
Telangiectasis, 652 
Tetter, 216 

Therapeutic notes, 47 
Thigenol, 55 
Thilanin, 55 
Thiolan, 55 
Thiosavonale, 55 
Tinctura saponis viridis, 718 
Tinea amiantacep, 586 

asbestina, 586 

barbae, 661 

circinata, 654 

decalvans, 105 

favosa, 305 

ficosa, 305 

embricata, 656 

kerion, 388 

lupinosa, 305 

maligna, 305 

nodosa, 496, 653 

sycosis, 661 

tonsurans, 657 

vera, 305 

versicolor, 148 
Tinna, 497 
Tongue, black, 130 

hairy, 130 
Toxi-tuberculides papulo necro- 

tiques, 320 
Trichauxis, 352 
Trichiasis, 653 
Trichoclasia, 119 



IXBEX. 



737 



Trichomycosis capillitii, 388 
favosa, 305 
nodosa, 496 
Trichonosis cana, 134 
discolor, 134 
poliosis, 134 
Trichophytosis, etiology, 663 
pathology, 664 
prognosis, 674 
symptoms, 654 
treatment, 666 
barbae, diagnosis, 662 

symptoms, 661 
capitis, diagnosis, 660 

symptoms, 657 
corporis, symptoms, 654 

diagnosis, 657 
unguium, diagnosis, 663 
symptoms, 662 
Trichoptylose, 119 
Trichorrhexis nodosa,119 
Trichosis hirsuties, 352 

plica, 507 
Tropical big leg, 259 
Tubercle, the, 31 

anatomical, 675 
Tuberculosis cutis, 675 
cutis orificialis, 675 
miliary, 675 
ulcerosa, 675 
verrucosa cutis, 675 
Tuberculum sebaceum, 443 
Tuinenol, 55 
Tumor, the, 34 

multiple fungoid, 450 
Tvloma, 133 
Tylosis, 143 
linguae, 403 
palmae et plantae, 385 



ULCER, the, 35, 679 
tropical phagedenic, 687 
Ulcus grave, 328 
pelorans, 492 
rodens, 270 
Ulerythema, 419, 681 
sycosiforme, 324 
Uridrosis, 682 
Urticaria, 'diagnosis, 686 
etiology, 685 
pathology, 685 
prognosis, 688 
symptoms, 683 
treatment, 687 
pigmentosa, 688 
Uviol lamp, 57 



T7ACCINIA, 6 
V Varicella, 



690 
690 
gangrenosa, 180 
Variola, 691 
Varioloid, 691 
Varus, 69 
Vasogen, 50 
Veld sore, 692 
Verole, 607 
Verruca, 692 

necrogenica, 675 
Verrue, 692 
Verruga, 705 

peruana, 696 
Vesicle, the, 32 
Vienna paste, 715 
Vitiligo, 696 

capitis, 105 
Vitiligoidea, 700 
Vleminckx's solution, 719 

WART, 692 
post mortem, 675 
Warze, 692 

Wash leather-skin, 700 
Weichselzopf, 507 
Wen, 161 
Wheal, the, 34 
Whelk, 69 
Whitlow, 475 

melanotic, 562 
Wildfire, 279 

Wilkinson's ointment, 722 
Wood-tick. 475 
Wundrose, 279 

X-RAY, 57 
dermatitis, 198 

Xanthelasma, 700 

Xanthelasmoidea, 688 

Xanthoma, 700 

diabeticorum, 704 

Xeroderma, 363 
ichthyodes, 363 
pigmentosum, 123 

Xerodermic pilaire, 386 

Xeroform, 56 

Xerosis, 118 

yAWS, 705 

ZONA, 206 
Zoster, diagnosis, 709 
etiology, 708 
pathology, 709 
prognosis, 710 
symptoms, 706 
treatment, 709 



AUG 1 1908 



